Transfusion of blood components is a complex process involving multiple departments, staff members, and steps. Accurate recipient identification at blood collection and administration is essential to the safety of the total blood transfusion process.

Whenever patients have multiple tubing lines connected to them, the potential for tubing misconnections increases. Liquid-to-liquid and liquid-to-gas misconnections can pose the most serious harm to patients.

Reported events describe how storage of medications in locations including the pharmacy, patient care areas, automated dispensing cabinets, and anesthesia carts have contributed to drug product mix-ups.

Three factors of rapid response preparedness must be addressed in clinical care areas: (1) rapid access to functioning equipment and up-to-date supplies, (2) knowledgeable and trained staff, and (3) maintaining a state of readiness.

Pennsylvania Patient Safety Authority analysts summarize results of their review of the clinical literature to determine the efficacy of probiotics for the prevention and treatment of gastrointestinal illness, including Clostridium difficile infection.

The Anesthesia Patient Safety Foundation offers a free video on its Web site that promotes best practices regarding the prevention of surgical fires in the operating room.

Pennsylvania ambulatory surgical facilities (ASFs) are required to develop and implement an internal infection control plan that includes procedures for identifying and designating patients with methicillin-resistant Staphylococcus aureus (MRSA). In response to requests from ASFs in Pennsylvania, the Pennsylvania Patient Safety Authority conducted a series of MRSA management workshops.

Pennsylvania Patient Safety Authority analysts identified eight hospitals that dramatically reduced their incidence of wrong-site surgery reports. The Authority interviewed the Patient Safety Officers or other personnel at these facilities to identify their successful efforts to eliminate wrong-site surgery.