Accurate interpretation and implementation of these documents, in addition to effective planning and communication, will help ensure that a patient’s end-of-life preferences for medical care are honored.

The admission diagnosis and documentation of Stage III or IV pressure ulcers is essential to overall pressure ulcer identification, care, and ultimately, reduction.

Medication errors in organizations that use bar-code systems for administration can result from failures to use this technology appropriately.

Improper application of the retainer and use of incorrect size, especially on digits, has caused harm to patients.

Review of pen performance and sterility may provide insight for evaluating surgical site marking pens.

A ruptured intravenous set can expose a patient or staff member to the contrast solution or blood and fluid.

Hospitals not capturing near-miss, or “Incident,” events are hurting their ability to identify and correct problems before they harm patients.

An editorial advisory board member questions if review of PA-PSRS reports can offer insight into whether there is a need for isolated power systems in the OR.

Implementing critical risk reduction strategies (e.g., baseline risk assessment, ongoing compliance monitoring) is essential to prevent, control, and eliminate multidrug-resistant organisms in healthcare settings.

Previous wrong-site surgery data has been updated according to information submitted during the last quarter (Q3-2008).

The Pennsylvania Patient Safety Advisory editorial staff has added the permission to reprint and copyright to the online version of this article for the infiltration scale that was reproduced on page 98.