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Patient Safety Authority
539 Forum Building
Harrisburg, PA 17120


Phone: 717-346-0469
Fax: 717-346-1090


  
Educational Tools 
Patient Safety Practices in Pennsylvania               Healthcare Facilities 
Patient Safety Practices in Pennsylvania Healthcare Practices 

Since its inception, the most challenging question asked of the Pennsylvania Patient Safety Authority is whether healthcare in Pennsylvania is becoming safer. To complement its efforts toward this goal, the Authority invited patient safety officers from all reporting facilities in Pennsylvania to participate in a survey initiative to measure the level of adoption of selected safety practices. The detailed aggregate results, a sample action agenda, and links to associated Advisory articles, are available here.
 

 Educational Tools
Aggregate Results: Patient Safety Practices in Pennsylvania Healthcare Facilities Survey
These aggregate results pertain to the Pennsylvania Patient Safety Authority's statewide survey of adoption of selected patient safety practices.
Action Agenda: Patient Safety Practices in Pennsylvania Healthcare Facilities
This action agenda is intended to assist in adoption of selected patient safety practices to reduce the risk of errors.

 Leadership Domain Articles
Leadership Series: Executive Patient Safety Walkrounds
Abington Memorial Hospital's patient safety staff members have been conducting patient safety walkrounds for several years and have witnessed an increasing level of popularity in the exercise from trustees and executives.
Leadership Series: Meaningful Engagement in Patient Safety Improvement
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.
Safety Leadership
A Pennsylvania healthcare leader addresses the important connection between an organization’s leadership and the success of the organization’s safety program.
The Role of Empowerment in Patient Safety
Procedures will only improve patient safety if team members feel empowered to act when they believe the procedures are not being followed.

 Medication Domain Articles
Anticoagulation Management Service: Safer Care, Maximizing Outcomes
Healthcare organizations have increasingly recognized the benefits of anticoagulation services in the inpatient and outpatient settings.
Sterile Water Should Not be Given Freely
Sterile water is hypotonic. Serious patient harm, including hemolysis, can result when it is administered by direct intravenous infusion.
Dangers Associated with Shared Multidose Vials
As recent national news has illustrated, multidose vial use in any patient care area is risky, with an ever-present danger for iatrogenic cross-contamination.
Medication Assessment: One Determinant of Falls Risk
The absence of appropriate assessments may result in patients who are at risk for falls receiving medications that increase falls risk.
Drug Labeling and Packaging—Looking Beyond What Meets the Eye
The design of medication packaging and labeling can contribute to errors such as incorrect drug dispensing. Factors such as readability, expression of drug strength or concentration, use of color, and lack of contrast can all affect the potential for an error to occur.
Inadvertent Mix-Up of Morphine and Hydromorphone: A Potent Error
Hydromorphone is a common alternative to morphine; however, hydromorphone’s analgesic equivalence must be considered because it is more potent than morphine when administered by any route.
Propofol Infusion Syndrome: A Rare but Potentially Fatal Reaction
This complex syndrome, associated with factors such as high doses of propofol, warrants attention to identify its mechanism, patients who are at risk, and methods of prevention.
Fentanyl Transdermal System: Taking Another Look
Errors involving these patches, such as multiple patches inadvertently applied, have resulted in significant patient harm.
Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety
Findings from the 30 hospitals participating in the workgroup show that pharmacy computer systems are not detecting unsafe orders as well as they could be.
Safety in Using Promethazine (Phenergan)
Longstanding familiarity with promethazine may mask its potential for patient harm, such as severe tissue damage, if not administered cautiously with proper patient monitoring.
Let's Stop the Bleeding: Preventing Errors with Heparin Therapy
Heparin is a high-alert medication that warrants unique handing during prescripting, dispensing, and administration.
Improving the Safety of Telephone or Verbal Orders
Following safe practices on verbal orders may help reduce the risk of misinterpretation.
Overdoses Caused By Confusion Between Insulin and Tuberculin Syringes
Errors in which tuberculin syringes were used in place of insulin syringes may be attributable to a resemblance in packaging of the two syringes.

 Safe Surgery Domain Articles
Editorial: WHO Surgical Safety Checklist
The Second Global Patient Safety Challenge: Safe Surgery Saves Lives initiative introduced this checklist, designed to catch omissions in the actions supporting an operation before the patient suffers harm.
Preventing the Retention of Foreign Objects during Interventional Radiology Procedures
Despite the minimally invasive nature of interventional radiology procedures, foreign objects may still be retained.
Insight into Preventing Wrong-Site Surgery
Incidence of wrong-site surgery has decreased in Pennsylvania, but PA-PSRS continues to receive reports of its occurrence. PA-PSRS’s analysis suggests opportunities for wrong-site surgery prevention.
Dangers Associated with Unlabeled Basins, Bowls, and Cups
Event reports indicate that unlabeled bowls, basins, and cups (containing medications and solutions) continue to be a problem.
Use of Checklists in Complex Environments
Reminders are an essential part of monitoring activities in complex environments such as healthcare. Incorporating checklists as reminders into the healthcare environment can yield beneficial results, such as improved compliance with best practices in clinical settings.
Hidden Sources of Latex in Healthcare Products
Latex exposure and allergic reactions continue to occur. It is important for healthcare providers to recognize latex-containing products and use suitable alternatives in situations that call for them.
Problems Related to Informed Consent
Excluding emergency or otherwise problematic cases, the commonly reported problem related to informed consent involved cases in which patients received several procedures during the same episode of care and consented to some procedures but not to others.

 Infection Control Domain Articles
Hand Hygiene Practices and the Use of Alcohol-Based Sanitizers
Use of alcohol hand sanitizers appears to be superior to traditional handwashing when the caregiver’s hands are not visibly soiled.
Prompt Identification and Effective Communication of Status May Reduce MRSA Infections
Failure to adequately identify and/or communicate patients’ MRSA statuses can perpetuate MRSA infection and transmission. Limiting the risk of MRSA transmission involves developing a comprehensive program that includes components such as active surveillance and ongoing evaluation of processes.

 Device Domain Articles
Smart Infusion Pump Technology: Don’t Bypass the Safety Catches
Using smart pumps to their fullest potential involves not only implementing this technology but also heeding alerts at the bedside.
Airway Fires during Surgery
Following safe practices can help reduce the likeliness of fires during airway surgery that involves ignition sources such as electrosurgical units.
Patient Receives Shock During Defibrillator Operational Check
Such an occurrence is preventable when visual and operational checks are performed by qualified clinical staff.
Forgotten But Not Gone: Tourniquets Left on Patients
Simple, practical tips developed by clinicians may help to reduce the systemic problem of tourniquets left on patients.
Skin Integrity Issues Associated with Pulse Oximetry
Event reports indicated that patients have sustained skin integrity injuries during pulse oximetry, including discolorations, blisters, lacerations, burns, and necrosis.
Electrosurgical Units and the Risk of Surgical Fires
Most surgical fires involve electrosurgery and begin when the electrosurgical unit is activated in an oxygen-enriched environments.

 Other Domain Articles
Hazardous Spills: The Safe Handling of Hazardous Drugs
Safe handling of hazardous drug spills is different from other healthcare spills. Exposure extends beyond patients and healthcare practitioners because nonclinical staff are often involved with containment and disposal.
In Vitro Hemolysis: Delays May Pose Safety Issues
Understanding the causes of in vitro hemolysis and corrective strategies to prevent it can help ensure that a quality specimen is obtained for analysis.
Update on Use of Color-Coded Patient Wristbands
The lack of consistency in wristband meanings and in how they are applied presents problems when patients are transferred among facilities and when patients are cared for by clinicians who work in multiple facilities.
Continuity of Oxygen Therapy During Intrahospital Transport
A heightened sensitivity to the critical nature of oxygen therapy is warranted because it requires multiple steps and multiple equipment connections.
Bed Exit Alarms to Reduce Fall Risk
Bed exit alarms can be an important component of fall prevention programs, but the technology may not always be used effectively.
Patient Identification
The potential for errors of patient identification may be greatest in acute care hospitals, where a wide range of interventions are delivered in various locations by numerous staff who work in shifts.
 
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