Unanticipated radiation exposure to an embryo/fetus may occur when women of childbearing age undergo diagnostic radiation procedures.

The absence of appropriate assessments may result in patients who are at risk for falls receiving medications that increase falls risk.

Failure to evaluate and/or diagnose stroke patients is a critical component in meeting the time constraints for treatment options.

Despite the minimally invasive nature of interventional radiology procedures, foreign objects may still be retained.

Failure to follow established procedures can result in lost or delayed specimens and inappropriate use, and ultimately impact patient care.

Ana Pujols-McKee, MD, chair of the Pennsylvania Patient Safety Authority Board of Directors, discusses getting “boards on board,” specifically, the trustees’ level of engagement in patient safety.

The director of surgery at a Pennsylvania hospital asks about incidence of surgical complications by day of the week. The Advisory welcomes letters to the editor, either in response to previous published articles or as questions or comments or alternative opinions consistent with the objectives of the Advisory

Healthcare facilities can refer to "Alarm Interventions during Medical Telemetry Monitoring: A Failure Mode and Effects Analysis," to understand telemetry monitoring alarm response processes and similar process failures and as an aid to develop facility-specific risk reduction strategies.

John R. Clarke, MD, editor, explains the Pennsylvania Patient Safety Advisory’s new format and new name. Highlights include an enriched table of contents, abstracts introducing scientific articles, and an editorial advisory board to assist in review and oversight of the quality of the publication.

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

Synopses are provided of 31 reports submitted through PA-PSRS that indicated an outcome of anoxic brain

The American College of Surgeons (ACS) recommends that healthcare facilities adopt certain operating room (OR) work practices to avoid surgeons’ and OR staff members’ exposure to bloodborne infections as a result of sharp injuries and surgical glove tears.

Assessing patients before, during, and after transport within the healthcare facility is an important strategy to mitigate potential harm to patients.