During analysis of events reported by Pennsylvania healthcare facilities, Authority analysts found evidence of unintended consequences that arose when patients were treated based solely on glucose meter results.

The Authority conducted a survey about violence protection practices in Pennsylvania acute care hospitals. The results suggest opportunities for improving violence protection practices to increase the safety of both emergency department patients and staff.

In early 2011, the reported incidence of lower respiratory tract infections (LRTIs) and influenza-like illnesses (ILIs) increased in Pennsylvania nursing homes, in comparison to previous reporting periods. Incidence of morbidity and mortality associated with ILI and LRTI can be decreased by means of prevention programs that target modifiable risk factors.

Patient Safety Liaison Michelle Bell, RN, BSN, FISMP, discusses a common patient safety challenge that patient safety officers identify during her facility visits: critical drug shortages. While such shortages are not preventable, they can be managed in a way that will decrease the likelihood of negative outcomes.

The results of this Authority project suggest that there is room to improve staff awareness about the value of reporting, the need to focus on system process redesign, and the nature and cause of human error.

Minnesota’s experience in working to establish a consistent and effective time-out process as the statewide community standard in hospitals and ambulatory surgery centers has provided a number of key lessons about how to develop and implement process changes within and across organizations.

The Authority’s published evidence-based best practice principles address deficiencies commonly found in the error analyses of wrong-site operative procedures, according to this assessment.

The U.S. Food and Drug Administration’s surgical fire prevention initiative is a collaborative effort between the clinical community and patient safety organizations to encourage safe practices and to develop interventions.

In response to medication errors reported to the U.S. Food and Drug Administration (FDA), the Institute for Safe Medication Practices, the Authority, and other reporting programs, FDA has approved labeling revisions to HYDROmorphone products to prevent associated medication errors.