Advisories & Events
Pennsylvania Patient Safety Advisory
Current Articles
201903
Reviews & Analyses
Mar 21, 2019
Patient Self-Harm in the Nonpsychiatric Setting
Acts of patient self-harm may challenge even the best-laid safety plans in unanticipated and potentially devastating ways. Pennsylvania healthcare facilities have reported more than 600 events describing intentional bodily harm outside of psychiatric settings, ranging from possession of means to self-harm to completion of a self-harm act.
Mar 21, 2019
Drug Shortages: Shortchanging Quality and Safe Patient Care
The struggle by healthcare providers to manage drug shortages has led to negative downstream effects on patients, including instances of unsafe or compromised practice and potentially harmful medication errors.
Mar 21, 2019
Exploring Vulnerability to Patient Safety Events along the Age Continuum
Attention to the event types and patterns of vulnerability that predominate in specific age cohorts may help facilities prioritize interventions.
From the Database
Mar 21, 2019
Incidence of Concurrent Surgery in Pennsylvania
In response to an inquiry, Patient Safety Authority analysts queried the Pennsylvania Patient Safety Reporting System database for events involving concurrent and overlapping surgery and procedures in hospitals and ambulatory surgical facilities.
Other Features
Mar 21, 2019
Are Humans the Problem in Patient Safety?
Encouraging humans to be adaptable improves their skill at navigating complexity, solving problems, and ultimately, improving patient safety.
Mar 21, 2019
Safety Stories: Missing the Mark
This recurring feature, in this example, highlights a hazard that exists if the individual drawing up medication does not recognize that a syringe is incorrectly marked.