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Pennsylvania Patient Safety Authority
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Safeguarding the Storage of Drug ProductsDescription: 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. Publication Date: 06-01-2010 Medication Errors in Labor and Delivery: Reducing Maternal and Fetal HarmDescription: Practitioners who work in labor and delivery units may administer
a variety of medications during the birthing process that, when
used in error, may adversely affect both the mother and the fetus.
In events reported to the Pennsylvania Patient Safety Authority, the
predominant medication error types associated with the labor and
delivery unit were dose-omission errors and wrong-drug errors. Publication Date: 12-16-2009 Confusion Regarding Concentration of Tamiflu® Oral SuspensionDescription: A shortage of commercially available Tamiflu® (oseltamivir phosphate) oral suspension is contributing to dosing errors in healthcare facilities. The Pennsylvania Patient Safety Authority has received two reports related to the concentration of Tamiflu. In each case, it was thought that the commercially available 12 mg/mL product and not a pharmacy-compounded 15 mg/mL suspension would be dispensed. Publication Date: 11-02-2009 An Update on the “Epi”demic: Events Involving EPINEPHrineDescription: Analysts revisit medication errors involving EPINEPHrine because events reported to the Pennsylvania Patient Safety Authority indicate that different types of errors occur with EPINEPHrine, many with the potential to cause patient harm. Publication Date: 09-01-2009 Hazardous Spills: The Safe Handling of Hazardous DrugsDescription: 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. Publication Date: 09-01-2008 Sterile Water Should Not be Given FreelyDescription: Sterile water is hypotonic. Serious patient harm, including hemolysis, can result when it is administered by direct intravenous infusion. Publication Date: 06-01-2008 The Big PictureDescription: Janet Johnston, RN, MSN, JD, retires from her position as a PA-PSRS patient safety analyst and shares her insight on the importance of recognizing the relationship between individual health-related tasks and the patient’s overall care. Publication Date: 09-01-2007 Drug Labeling and Packaging—Looking Beyond What Meets the EyeDescription: 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. Publication Date: 09-01-2007 Safety in Using Promethazine (Phenergan)Description: Longstanding familiarity with promethazine may mask its potential for patient harm, such as severe tissue damage, if not administered cautiously with proper patient monitoring. Publication Date: 03-31-2007 Purple Glove SyndromeDescription: An invited specialist comments on purple glove syndrome, an adverse drug reaction related to intravenous administration of phenytoin (DILANTIN). Publication Date: 12-01-2006 Looking Beyond the Obvious Causes of ErrorDescription: Understanding the causes of medication errors requires focusing on the medication use system (e.g., obtaining patient information, communicating drug orders). Publication Date: 09-01-2006 What the "L" is the Dose?Description: Certain letters and numerals (lower case letter "l" and number 1) can be interpreted different than the writer intended in medication orders, potentially resulting in medication errors. Publication Date: 09-01-2006 Abbreviation GotchasDescription: Misunderstanding of abbreviations is a frequent happenstance; these examples relate to medication orders. Publication Date: 06-01-2006 Demerol: Is It the Best Analgesic?Description: Considering Demerol's potential to stimulate seizures, its effect on the central nervous system, and its anticholinergic effect, this drug may not be the optimal analgesic for treating pain. Publication Date: 06-01-2006 hydrOXYzene and hydrALAzine Mix-UpsDescription: These drugs continue to be mistaken for one another due to similar names and are frequently stored next to each other on pharmacy shelves. Publication Date: 06-01-2006 Hold on to These OrdersDescription: Reports demonstrate that how we communicate orders to hold a medication can result in medication errors. Publication Date: 03-01-2006 PT—How Many Meanings?Description: Medical abbreviations are subjective, and because of variation they may not always be understood or correctly interpreted. Publication Date: 09-01-2005 Anesthesia AwarenessDescription: Anesthesia awareness has historically been under-recognized and under-treated; however, estimates indicate that approximately 100 cases occur daily in the United States. Publication Date: 09-01-2005 Spotted Again: Insulin/TB Syringe ConfusionDescription: An event report about insulin and tuberculin syringe confusion prompts revisiting this topic, which was first highlighted in the October 28, 2004, supplementary Advisory. Publication Date: 06-01-2005 PCA by Proxy—An Overdose of CareDescription: When used as intended, patient-controlled analgesia (PCA) reduces the risk of oversedation; however, incorrect use by individuals other than the patient can place the patient at risk for over-sedation, respiratory depression, and even death. Publication Date: 06-01-2005 Complexity of Insulin TherapyDescription: Nearly 16% of Serious Events submitted through PA-PSRS involved the use of insulin, a high-alert medication. Publication Date: 06-01-2005 Give 40 of K—You Know What I Mean, Don't You?Description: A verbal order from the physician that includes all the necessary elements and is read back by the nurse for verification could reduce errors related to the verbal mode of prescribing. Publication Date: 03-01-2005 Multiple Messages, Multiple TasksDescription: After an event is determined to be the result of ineffective communication, two salient points include (1) fewer intermediaries create fewer opportunities for misunderstanding and (2) the less that intermediaries understand about the message, the greater the chance for misunderstanding. Publication Date: 03-01-2005 Topical Anesthetic-Induced MethemoglobinemiaDescription: Many topical anesthetic sprays have been implicated in cases of methemoglobinemia, a serious and sometimes fatal adverse drug reaction. Publication Date: 03-01-2005 Follow-up on Previous Advisory ArticlesDescription: Patient Safety Officers share feedback and follow-up on two topics of previous Advisory issues (i.e., insulin and tuberculin syringe confusion, time out processes). Publication Date: 12-01-2004 Medications Contributing to Fall RiskDescription: Approximately 21% of reports of patient falls indicate that the patient was receiving one or more drugs that can contribute to falls risk. Publication Date: 12-01-2004 Focus on High-Alert MedicationsDescription: Approximately one in four medication error reports submitted through PA-PSRS involves a high-alert medication. Publication Date: 09-01-2004 Patient IdentificationDescription: 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. Publication Date: 06-01-2004 |
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HYDROmorphone Measures WorksheetDescription: This sample worksheet may be used for documenting facility-specific process and outcome measures involving the use of HYDROmorphone. Publication Date: 09-01-2010 Prescribing Considerations for HYDROmorphoneDescription: This excerpt from the package insert for HYDROmorphone is intended to provide information about the appropriate prescribing of HYDROmorphone. Publication Date: 09-01-2010 Insulin Measures WorksheetDescription: This sample worksheet may be used for documenting facility-specific process and outcome measures involving the use of insulin. Publication Date: 03-01-2010 Sample Policy on Verbal/Telephone OrdersDescription: This sample policy, intended to help reduce errors associated with misinterpreted verbal or telephone communications of medication orders or test results, can be adapted to be facility specific. Publication Date: 06-01-2006 |
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