The Pennsylvania Patient Safety Authority sponsored a multihospital collaborative to measure blood specimen labeling error rates, document hospital-specific interventions to reduce the labeling error rate, and measure the outcome of the interventions. The collaborative resulted in a statistically significant decrease in specimen labeling errors.

Targeted improvements in averting venous thromboembolism in Pennsylvania hospitals during 2010 resulted in statistically significant reductions in the participating hospitals’ deep venous thrombosis and pulmonary embolism rates.

Review of reported radiologic events in Pennsylvania identified specific processes that exposed patients to potential harm, including order and scheduling inaccuracies, patient misidentification, and inaccurate procedure verification practices. Implementation of simple system safeguards can help to mitigate this unnecessary patient risk.

Misperceptions about safe injection practices can lead to breaches in infection control such as unsafe syringe use and contamination of shared medication by reused syringes. National outbreaks of hepatitis B and hepatitis C indicate an urgent need to ensure safe injection practices during healthcare delivery.

Event report analysis indicates that methotrexate dosing errors (e.g., wrong dose/overdosage, dose omission) similar to those cited in the medical literature have been occurring in Pennsylvania.

Recent event reports exemplify the value of a properly conducted time-out. In this update, Pennsylvania Patient Safety Authority emphasizes principles that should be followed during a time-out and shares results from a survey of Pennsylvania operating room managers about their time-out processes.

The Pennsylvania Patient Safety Authority’s experience with its collaborative learning model has been encouraging so far. The Authority is optimistic that the model’s five components will help healthcare facilities in Pennsylvania provide safe care to patients.

Patient Safety Liaison Megan Shetterly, RN, MS, shares participants’ experiences (e.g., changing facility culture) from the Pennsylvania Patient Safety Authority’s collaborative to improve blood specimen labeling.

This article contained statements in error about reports of non-Clostrodium difficile acute gastroenteritis cases in nursing homes in Pennsylvania.