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Pennsylvania Patient Safety Authority
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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 Diagnostic Error in Acute CareDescription: Misdiagnosis-related harm is preventable. Healthcare facilities have many strategies at their disposal that can help reduce diagnostic error rates. 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 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 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 Data Snapshot: Maternal ComplicationsDescription: A search of the Pennsylvania Patient Safety Authority's reporting
system database results in identification of 256 reports of maternal
complications causing harm to mothers. Publication Date: 12-16-2009 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 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 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 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 Rapid Response in the Operating RoomDescription: Rapid response teams have proven effective for hospitalized patients in distress outside of critical care areas. Publication Date: 09-01-2008 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 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 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 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 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 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 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 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 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 Letter to the Editor: PCA by ProxyDescription: A nurse comments on a Sentinel Event Alert regarding patient-controlled analgesia (PCA) by proxy, and her facility's subsequent examination of its safety measures. 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 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 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 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 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 |
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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 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 Diagnostic Error Measures WorksheetDescription: This sample worksheet may be used for documenting facility-specific process and outcome measures involving physician misdiagnosis. Publication Date: 09-01-2010 DEER Taxonomy Chart Audit ToolDescription: This adapted audit tool may be used to classify where a failure occurred during the diagnostic process. Publication Date: 09-01-2010 A Physician Checklist for DiagnosisDescription: This pocket resource for physicians includes a general checklist designed to minimize diagnostic error. Publication Date: 09-01-2010 Patient Education Regarding Diagnostic ErrorDescription: This sample handout is intended to help healthcare providers encourage patients to be active participants in each and every physician encounter. 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 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 |
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