Motivated by the lack of medical literature that quantitatively addresses medication errors occurring in ambulatory surgical settings, analysts reviewed medication errors reported to the Authority.

Patient-controlled analgesic (PCA) therapy is an effective way to provide pain management. However, reports illustrate the multiple ways that errors with PCA happen frequently, sometimes with tragic consequences.

Analysis of event data reported by Pennsylvania acute care facilities suggests that the facilities would benefit from greater attention on catheter maintenance, in addition to complying with best practices during catheter insertion.

In response to an inquiry, Pennsylvania Patient Safety Authority analysts revisited interventions to mitigate human and equipment failures associated with reported alarm monitoring events.

Pennsylvania Patient Safety Authority analysts reviewed the 444 wrong-site surgery reports submitted since June 2004 to identify the possible impact of 21 best practice principles for preventing wrong-site surgery.

Senior leadership can create an atmosphere of empowerment that will engage their employees in delivering safer patient care.