|
|
|
Pennsylvania Patient Safety Authority
|
|
|
|
|
|
|
|
|
Quarterly Update on the Preventing Wrong-Site Surgery ProjectDescription: Three years have passed since the first definitive article from the Pennsylvania Patient Safety Authority on wrong-site surgery. After that initial focus on wrong-site surgery, the number of events has decreased each year. Facilities reported 14 events during the last quarter (April through June 2010). Publication Date: 09-01-2010 Strategies for Avoiding Problems with the Use of Pneumatic TourniquetsDescription: Failure or misuse of pneumatic tourniquets can lead to muscle ischemia, nerve damage, convulsions, and coma. Addressing cuff availability and educating staff about cuff selection, application, and inflation pressure are fundamental strategies to avoid complications. Publication Date: 09-01-2010 Patient Safety is Enhanced by TeamworkDescription: Patient Safety Liaison Christina Hunt, RN, MSN, MBA, HCM, discusses a foundational teamwork program that facilities can use to help provide healthcare workers with the necessary strategies and tools to reduce errors. Publication Date: 06-16-2010 Chain of Command: When Disruptive Behavior Affects Communication and TeamworkDescription: In healthcare, individuals that participate in disruptive behavior may delay communication between clinicians, potentially resulting in delays in patient care. A facility that values all clinicians is one that invests in chain-of-command policies and adequately investigates and follows up on reports of disruptive behaviors. Publication Date: 06-09-2010 Tubing Misconnections: Making the Connection to Patient SafetyDescription: Whenever patients have multiple tubing lines connected to them, the potential for tubing misconnections increases. Liquid-to-liquid and liquid-to-gas misconnections can pose the most serious harm to patients. Publication Date: 06-01-2010 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 OR Fire Prevention Video AvailableDescription: The Anesthesia Patient Safety Foundation offers a free video on its Web site that promotes best practices regarding the prevention of surgical fires in the operating room. Publication Date: 06-01-2010 Management of MRSA in Ambulatory Surgical FacilitiesDescription: Pennsylvania ambulatory surgical facilities (ASFs) are required to develop and implement an internal infection control plan that includes procedures for identifying and designating patients with methicillin-resistant Staphylococcus aureus (MRSA). In response to requests from ASFs in Pennsylvania, the Pennsylvania Patient Safety Authority conducted a series of MRSA management workshops. Publication Date: 06-01-2010 Quarterly Update on the Preventing Wrong-Site Surgery ProjectDescription: Pennsylvania Patient Safety Authority analysts identified eight hospitals that dramatically reduced their incidence of wrong-site surgery reports. The Authority interviewed the Patient Safety Officers or other personnel at these facilities to identify their successful efforts to eliminate wrong-site surgery. Publication Date: 06-01-2010 Get to Know Your PSLDescription: The Pennsylvania Patient Safety Authority’s Patient Safety Liaisons provide guidance, coordinate educational programs, encourage collaboration, and solicit feedback from healthcare facilities that report Incidents and Serious Events under Act 13 of 2002. Publication Date: 03-01-2010 Corneal Abrasion InjuriesDescription: In response to an inquiry by a Pennsylvania Patient Safety Officer, Pennsylvania Patient Safety Authority analysts reviewed reports involving corneal abrasions. Publication Date: 12-01-2009 Editorial: None Is PerfectDescription: There are lessons to be learned from recent, adverse experiences in a model healthcare system that made nationwide news, not the least of which is that patient safety is an integral part of the reliable delivery of quality healthcare and of quality improvement. Publication Date: 09-01-2009 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 Beyond the Count: Preventing the Retention of Foreign ObjectsDescription: Surgical counts are intended to prevent the retention of a sponge, sharp, or instrument during a surgical procedure, yet despite the highly regulated nature of the process, discrepancies in the surgical count occur. Publication Date: 06-01-2009 Quarterly Update on the Preventing Wrong-Site Surgery ProjectDescription: Twelve wrong-site surgeries were reported during the first quarter of 2009 (Q1-2009). In this update, analytical commentary accompanies the report accounts to emphasize previously discussed principles of preventing wrong-site surgery. Publication Date: 06-01-2009 Patient Safety in Pennsylvania Healthcare FacilitiesDescription: The Pennsylvania Patient Safety 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. Publication Date: 06-01-2009 Patient Screening and Assessment in Ambulatory Surgical FacilitiesDescription: As the popularity of these facilities continues to grow and increasingly complex procedures are performed, thorough screening, assessment, and preparation of patients prior to surgery is essential to ensure optimal patient outcomes. Publication Date: 03-01-2009 Data Snapshot: Iatrogenic Burn InjuriesDescription: A recent article in the Wall Street Journal led Authority analysts to query the PA-PSRS database for burn related reports submitted in 2007. Publication Date: 03-01-2009 Multidrug-Resistant Organisms—Strategies to Reduce InfectionDescription: Implementing critical risk reduction strategies (e.g., baseline risk assessment, ongoing compliance monitoring) is essential to prevent, control, and eliminate multidrug-resistant organisms in healthcare settings. Publication Date: 12-01-2008 Forcing Functions of Antibiotic ProphylaxisDescription: Introducing certain forcing functions can help improve physician behavior associated with use of prophylactic antibiotics in preventing surgical site infections, according to a program undertaken at Temple University Hospital. Publication Date: 09-01-2008 Editorial: WHO Surgical Safety ChecklistDescription: 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. Publication Date: 09-01-2008 Act 52 of 2007: the Authority’s Role, Progress to Date, and Future GoalsDescription: Hospitals and nursing homes are required by 2007 legislation to report healthcare-associated infections (HAIs) to the Pennsylvania Patient Safety Authority. Ongoing collection and analysis of HAI-related data from more than 250 hospitals and 800 nursing homes will assist the Authority in identifying trends, patterns, and potential process or system failures. Publication Date: 06-01-2008 Letter to the Editor: Surgical Complication IncidenceDescription: The director of surgery at a Pennsylvania hospital asks about incidence of surgical complications by day of the week. The Advisory welcomes letters to the editor, either in response to previous published articles or as questions or comments or alternative opinions consistent with the objectives of the Advisory Publication Date: 03-01-2008 The American College of Surgeons Recommends Sharps Safety PracticesDescription: The American College of Surgeons (ACS) recommends that healthcare facilities adopt certain operating room (OR) work practices to avoid surgeons’ and OR staff members’ exposure to bloodborne infections as a result of sharp injuries and surgical glove tears. Publication Date: 03-01-2008 Insight into Preventing Wrong-Site SurgeryDescription: 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. Publication Date: 12-01-2007 Reducing Complications from Interscalene BlocksDescription: An interscalene block (ISB) is an effective anesthetic technique with many advantages, but it is associated with certain complications, such as seizure and arrhythmia. Implementing specific risk reduction strategies before, during, and after ISB may help patients realize the benefits of ISB without the associated complications. Publication Date: 12-01-2007 Hats Off to the Unsung HeroesDescription: All healthcare workers can have an influential role in preventing patient harm, not just those staff members who are most directly involved with patient care. Publication Date: 12-01-2007 Deaths Following Ambulatory SurgeryDescription: Analysis of reports of patient deaths following ambulatory surgery emphasizes the need for ambulatory surgical facilities to be able to respond to emergency conditions. Publication Date: 09-01-2007 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 Query on Wrong-Site SurgeryDescription: A reader questions whether the analysis of wrong-site surgery events reported in Pennsylvania and the resulting article adequately addresses the responsibility of physicians in preventing wrong-site surgery. Publication Date: 09-01-2007 Profitability is Associated with Reporting Patient Safety EventsDescription: There is a small, yet significant relationship between the number of reports per licensed bed of an acute care hospital and its operating margin, according to analysis of reports submitted to PA-PSRS and the Pennsylvania Health Care Cost Containment Council’s 2006 financial report. Publication Date: 09-01-2007 Preventing Adverse Events Related to Chest Tube InsertionDescription: A tutorial program for physicians that discusses four sources of adverse outcomes during chest tube insertion (e.g., incorrect surgical technique) is available from the U.S. Agency for Healthcare Research and Quality. Examples of these sources of adverse outcomes are apparent in reports to PA-PSRS. Publication Date: 09-01-2007 Safety LeadershipDescription: A Pennsylvania healthcare leader addresses the important connection between an organization’s leadership and the success of the organization’s safety program. Publication Date: 06-01-2007 Doing the Right Things to Correct Wrong-Site SurgeryDescription: Wrong-site surgery that touches the patient is expected to occur once a year in the operating room of a 300-bed hospital. Considering wrong-site surgery prevention processes as a whole is an important strategy to preventing wrong-site surgery. Publication Date: 06-01-2007 Going Beyond the Simple FixDescription: A facility identifies and implements changes in response to a near miss, then continues to look for system improvement opportunities. Publication Date: 06-01-2007 Query on Clostridium DifficileDescription: A reader questions the efficacy of alcohol-based hand rubs in preventing the transmission of C. difficile. Publication Date: 04-01-2007 Helping the Authority to Help YouDescription: In December 2006 and January 2007, the Pennsylvania Patient Safety Authority hosted discussion groups of Patient Safety Officers. A full report on the discussions is available. Publication Date: 03-31-2007 Complications of Retrobulbar BlocksDescription: PA-PSRS has received reports of complications of retrobulbar blocks, including central nervous system spread of anesthesia, retrobulbar hemorrhages, respiratory arrest, and death, despite the declining use of this technique in favor of topical anesthetics. Publication Date: 03-31-2007 Follow Up on TassDescription: An online educational program, "Get the Facts on Toxic Anterior Segment Syndrome," is available about the etiology of and care and treatment for TASS. Publication Date: 03-31-2007 Standardization: Autonomy versus ConsensusDescription: John R. Clarke, MD, editor, discusses this subtle yet important difference in achieving consistently good patient care systemwide. Publication Date: 03-31-2007 Airway Fires during SurgeryDescription: Following safe practices can help reduce the likeliness of fires during airway surgery that involves ignition sources such as electrosurgical units. Publication Date: 03-31-2007 Remain Steadfast in Patient Safety EffortsDescription: The Patient Safety Authority administrator discusses the growth of the Patient Safety Advisory with each successive issue and encourages Pennsylvania healthcare facilities to continue to use the Advisory and other associated resources to improve patient safety. Publication Date: 12-01-2006 Bone Cement Implantation SyndromeDescription: Intraoperative deaths during hip arthroplasty are rare, but often fatal. Bone cement implantation syndrome is a well-recognized complex of sudden physiologic changes that occur within minutes of the use of methyl methacrylate cement. Publication Date: 12-01-2006 Perforations of the Colon during ColonoscopiesDescription: John R. Clarke, M.D., Clinical Director of PA-PSRS, invites providers who perform colonoscopies to participate in a statewide safety initiative to reduce the risk of colon perforations during colonoscopy. Publication Date: 12-01-2006 Patient Safety Authority Receives 2006 Eisenberg AwardDescription: The Patient Safety Authority receives the Joint Commission award in acknowledgement of the Authority's impact on patient safety on a regional level because of efforts to develop nationally recognized resource. Publication Date: 09-01-2006 Letter to the Editor: Color-Coded Patient WristbandsDescription: Readers compliment work-to-date in Pennsylvania on color-coded wristbands, recommend consideration of isolation patients, and raise the question of nationwide standardization. Publication Date: 09-01-2006 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 Delays in the OR: Stress Between "Running Two Rooms" and "Time Outs"Description: While there are many, often unavoidable reasons for delays in the operating room, addressing scheduling, transfer of care, case notification, and delays while patients are under anesthesia can help minimize the risk of procedure delays. 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 Pressure Ulcers: A Look at Reports to PA-PSRSDescription: Facilities may be missing opportunities to improve quality of care if they fail to assess patients for risk of developing pressure ulcers and fail to collect information about stages of any pressure ulcers that develop. Publication Date: 09-01-2006 Update on Use of Color-Coded Patient WristbandsDescription: 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. Publication Date: 08-09-2006 Implementing Change Through PA-PSRSDescription: Event reports submitted through PA-PSRS drive the publication of individual Advisory articles that suggest clinical protocols facilities can implement to prevent the occurrence of similar events. Publication Date: 06-01-2006 Abbreviation GotchasDescription: Misunderstanding of abbreviations is a frequent happenstance; these examples relate to medication orders. Publication Date: 06-01-2006 Threat of Cornea Transplant ContaminationDescription: A cornea implantation that potentially came from a donor with hepatitis B prompted one hospital to identify and adopt new procedures for tissue handling. 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 Responding to Adverse EventsDescription: While the action of reporting an adverse event involves only staff and administrators at a particular facility, the process of disclosure engages the patient and his family as well. Publication Date: 03-01-2006 Bioburden on Surgical InstrumentsDescription: Reports of soiled instruments contaminating surgical fields emphasize the importance of performing quality control on each step of equipment preparation: cleaning, disinfecting, and sterilizing. Publication Date: 03-01-2006 Electrosurgery Safety IssuesDescription: More than half of electrosurgery unit- (ESU-) related burns and fires are attributable to inadvertent ESU activation, which is easily prevented. Publication Date: 03-01-2006 Use of Color-Coded Patient Wristbands Creates Unnecessary RiskDescription: 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. Publication Date: 12-14-2005 Developing a Culture of SafetyDescription: Articles in the medical literature provide insight into the issues surrounding the development of a culture of safety. Publication Date: 12-01-2005 Brevity is the Soul of Wit, but Not of SafetyDescription: Understanding of events, such as overdose of morphine by means of patient-controlled analgesia, is only possible through thorough event reporting. Publication Date: 12-01-2005 IHI Offers Patient Safety Leadership GuideDescription: The Institute for Healthcare Improvement offers a leadership guide that outlines eight steps healthcare leaders can use to improve safety in their organizations. Publication Date: 12-01-2005 The Highly Reliable Operating TeamDescription: Notes from a panel discussion of the American College of Surgeons convey how surgeons can improve the safety of the operating team. Publication Date: 12-01-2005 Continuous Care Throughout Patient TransferDescription: Distinct patterns have emerged from event reports related to intrahospital transfers, including equipment availability, communication, staff deployment, and readiness to support patients' needs. Publication Date: 12-01-2005 Workarounds: A Sign of Opportunity KnockingDescription: While a workaround provides a temporary solution to an immediate problem, it is also a symptom of a system that may need improvement. Publication Date: 12-01-2005 Why Near-Miss Reporting MattersDescription: Reporting near misses can benefit organizations if the reports are examined and corrective measures are implemented. Publication Date: 09-01-2005 Lost Surgical Specimens, Lost OpportunitiesDescription: The substantial increase in the volume of ambulatory surgical procedures increases the need to prepare for delivering unanticipated patient care and safe transfers to hospitals. Publication Date: 09-01-2005 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 Update on Alcohol-Based Surgical Prep SolutionsDescription: Since publication of the June 2005 Patient Safety Advisory article "Risk of Fire from Alcohol-Based Solutions," the National Fire Protection Association amended its standards to permit the use of flammable liquid germicides provided specific precautions are followed. 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 Patient Safety Authority UpdateDescription: At the one-year anniversary mark of PA-PSRS, discussion centers on how the program has improved patient safety in Pennsylvania. Publication Date: 06-01-2005 PA-PSRS Pointers: Avoiding Betadine BurnsDescription: Skin irritation and severe skin reactions may occur when wet, unevaporated Betadine solution comes in prolonged contact with the skin. Publication Date: 06-01-2005 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 Skin Integrity Issues Associated with Pulse OximetryDescription: Event reports indicated that patients have sustained skin integrity injuries during pulse oximetry, including discolorations, blisters, lacerations, burns, and necrosis. 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 Convenience at a CostDescription: Two hazardous practices are linked to reports of pieces of intravenous catheters being left in patients and embolizing: (1) modifying the ends of previously laced catheters, which can cause retained catheter fragments; and (2) using oxygen flow selectors in a manner that can cut off the patient's supplemental oxygen supply. Publication Date: 04-21-2005 Patient Safety Authority UpdateDescription: Patient safety is everybody's business. The information published in the Advisory is relevant for all clinicians and is intended to be distributed to as many individuals in healthcare facilities as possible. Publication Date: 03-01-2005 When Patients Speak—Collaboration in Patient SafetyDescription: Patients can offer key input into their own safety when given the opportunity, including rapidly identifying side effects or adverse events, ensuring that treatment is given, deciding on treatment, and helping to achieve accurate diagnosis. Publication Date: 03-01-2005 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 Focusing on Eye SurgeryDescription: Two distinct patterns emerge from event reports involving eye surgery: (1) wrong-side surgery and (2) problems with intraocular lens implants. 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 Patient Safety Authority UpdateDescription: Five years after the release of the seminal report, To Err is Human, and six months after the start of PA-PSRS, how are Pennsylvania facilities responding to patient safety? Publication Date: 12-01-2004 The Role of Empowerment in Patient SafetyDescription: Procedures will only improve patient safety if team members feel empowered to act when they believe the procedures are not being followed. Publication Date: 12-01-2004 Risk of Unnecessary Gall Bladder SurgeryDescription: Event reports discuss attempted cholecystectomy procedures in patients who had previously had their gall bladders removed; these previous procedures did not become known until the patients' surgeries were performed. Publication Date: 12-01-2004 Snip-It SafetyDescription: Reported scissors-related injuries include superficial nicks, lacerations, and even a case of amputation of a finger tip; lessons learned focus on avoidance, assessment, use of blunt instruments, visibility, control, and positioning. Publication Date: 12-01-2004 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 A Rare but Potentially Fatal Complication of ColonoscopyDescription: If a healthcare team has a high index of suspicion of splenic injury in patients who develop abdominal symptoms after colonoscopy, successful outcomes from this rare complication are more likely to occur. Publication Date: 12-01-2004 Understanding the Benchmarking ProcessDescription: To be effective, benchmarking must provide a systematic method of understanding the underlying process that determines an organization's performance. Publication Date: 12-01-2004 Patient Safety Authority UpdateDescription: PA-PSRS continues to receive recognition as an innovative approach to promoting patient safety and reducing medical errors. Publication Date: 09-01-2004 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 Use of Checklists in Complex EnvironmentsDescription: 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. Publication Date: 09-01-2004 Two Takes on the Time OutDescription: Event reports demonstrate (1) that the time out can be useful defense against wrong-site surgery and (2) problems with implementing the time out may limit its benefits. Publication Date: 09-01-2004 Bed Exit Alarms to Reduce Fall RiskDescription: Bed exit alarms can be an important component of fall prevention programs, but the technology may not always be used effectively. Publication Date: 09-01-2004 Web Resources for Fall Prevention ProgramsDescription: Online resources for fall prevention programs include the Premier Safety Institute, the Southern California Evidence-Based Practice Center, and the National Guideline Clearinghouse. Publication Date: 09-01-2004 Hidden Sources of Latex in Healthcare ProductsDescription: 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. Publication Date: 06-01-2004 Problems Related to Informed ConsentDescription: 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. Publication Date: 06-01-2004 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 |
|
|
|
Strategies for Pneumatic Tourniquet UseDescription: This educational poster highlights fundamental strategies (e.g., cuff selection) for facilities to address with staff. Publication Date: 09-01-2010 Wrong Spinal Level Analysis FormDescription: This form is an addendum to the "Wrong-Site Surgery Error Analysis Form" and should complement the main form, as applicable. Publication Date: 04-01-2010 Wrong Ureter Analysis FormDescription: This form is an addendum to the "Wrong-Site Surgery Error Analysis Form" and should complement the main form, as applicable. Publication Date: 04-01-2010 Wrong-Site Surgery Error Analysis FormDescription: Anyone faced with a wrong-site surgery near miss or occurrence in his or her facility is encouraged to use this form to aid in the analysis. Publication Date: 04-01-2010 Bedside Invasive ProcedureDescription: Facilities can use this form for documentation of a bedside procedure time-out. Publication Date: 03-18-2010 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 Table 1. Marking Experiences Listed by MarkersDescription: The Pennsylvania Patient Safety Authority surveyed operating room managers about their experiences with using various marking pens with various skin preparation agents. The following table lists experiences according to markers. Publication Date: 09-01-2009 Table 2. Marking Experiences Listed by Skin Preparation AgentsDescription: The Pennsylvania Patient Safety Authority surveyed operating room managers about their experiences with using various marking pens with various skin preparation agents. The following table lists experiences according to skin preparation agents. Publication Date: 09-01-2009 Principles for Reliable Performance of Correct-Site SurgeryDescription: If surgical facilities are to hold their gains in consistently performing correct-site surgery, these principles for reliable performance of correct-site surgery, identified by the Pennsylvania Patient Safety Authority during its Preventing Wrong-Site Surgery Project, should be consistently followed. Publication Date: 09-01-2009 Retained Foreign Object Audit FormDescription: This sample form may be used for auditing events involving the unintentional retention of a foreign object. Publication Date: 06-01-2009 Time-Out in the OR CompetitionDescription: Script entries for the Authority's Time-Out in the OR Competition are depicted here. Publication Date: 03-01-2009 Health HistoryDescription: This sample form may be sent to the primary care physician or the referring physician for completion before the day of surgery. This form may be reviewed by anesthesia and nursing staff before the day of surgery, according to facility policy and procedures. Publication Date: 03-01-2009 Nursing Preoperative ScreeningDescription: This sample form may be used for nursing preadmission before the day of surgery. This form may be used for telephone or in-person screening and modified per facility policy and procedure. Publication Date: 03-01-2009 How Can You Prevent Wrong-Site Surgery?Description: Surgeons or facilities can give this brochure to preoperative patients so that they understand why so many providers ask the same questions. Facility-specific logos or contact information can be added to personalize the brochure. Publication Date: 12-01-2008 Day of Surgery: Standardized Independent Verification 1Description: This sample verification form includes elements pertinent to verifying patient information, medical documentation, and surgical information. It has been suggested that two independent healthcare providers independently verify the information and documentation before the start of the procedure. Publication Date: 06-01-2008 Day of Surgery: Standardized Independent Verification 2Description: This sample verification form includes elements pertinent to verifying patient information, medical documentation, and surgical information. It has been suggested that two independent healthcare providers independently verify the information and documentation before the start of the procedure. Publication Date: 06-01-2008 OR Scheduling FormDescription: This sample form includes suggested elements pertinent to scheduling cases for the operating room. Publication Date: 06-01-2008 Preoperative ChecklistDescription: This sample checklist includes suggested elements pertinent to checking patient information, medical documentation, and surgical information. Publication Date: 06-01-2008 The Awareness of Information in the Operating RoomDescription: This figure discusses the awareness of information in the operating room, including information from the schedule, medical record, and consent, as well as patient input. Publication Date: 12-01-2007 Obstructive Sleep Apnea Preoperative Screening ToolDescription: This sample questionnaire is not a substitute for a sleep disorder evaluation by a qualified physician, but it may help identify at-risk patients during the preoperative period. Publication Date: 09-01-2007 Airway Fires during SurgeryDescription: Airway surgeries that involve ignition sources to cut or coagulate tissue pose a significant and sometimes deadly risk of fire. This poster discusses ways to minimize and fight airway fires. Publication Date: 03-01-2007 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 Standardizing Colored Wrist Bands to Support Patient SafetyDescription: This brochure can be used to reinforce a healthcare facility's decision to participate in a patient safety initiative which is aimed at reducing the risks associated with the use of colored wristbands. Publication Date: 04-01-2006 Use of Color-Coded Wristbands Creates Unnecessary RiskDescription: This research poster identifies the risk of color-coded wristbands, the results of a usage survey conducted among Pennsylvania patient safety officers, and risk reduction strategies. Publication Date: 04-01-2006 Banding Together for Patient SafetyDescription: This educational poster can be used or adapted to reinforce the relationships between the color-coded wristbands and their meanings in specific healthcare facilities. Publication Date: 04-01-2006 |
|
|
|
Why You Should Get the Pneumonia VaccineDescription: Flu and pneumonia are significant causes of death from vaccine-preventable diseases, with 90 percent of these deaths occurring in adults age 65 or older, including those residing in long-term care facilities. Publication Date: 12-01-2009 |
|
|
|
|
|
| |
|
|
| |
|
|
|
|