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Pennsylvania Patient Safety Authority
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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 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 Clinical Emergency: Are You Ready in Any Setting?Description: Three factors of rapid response preparedness must be addressed in clinical care areas: (1) rapid access to functioning equipment and up-to-date supplies, (2) knowledgeable and trained staff, and (3) maintaining a state of readiness. Publication Date: 06-01-2010 Understanding Living Wills and DNR OrdersDescription: Accurate interpretation and implementation of these documents, in addition to effective planning and communication, will help ensure that a patient’s end-of-life preferences for medical care are honored. Publication Date: 12-01-2008 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 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 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 Diligence and Design in Behaviorial Health Impact Patient SafetyDescription: Many patients admitted to behavioral health facilities are at risk for harming themselves or others; however, facilities can address the associated risk factors using risk reduction strategies discussed in this article. Publication Date: 09-01-2007 Baxter Colleague Volumetric Infusion Pump: Product Recall NotificationDescription: Incidence of PA-PSRS reports following documented problems related to the Colleague series pumps suggests that efforts to address these problems may not have reached all clinical settings or facilities and that additional awareness may help reduce some infusion pump failures. Publication Date: 03-31-2007 I'm Stuck and I Can't Get Out! Hospital Bed EntrapmentDescription: Entrapment involves a patient who is caught, trapped, or entangled in the bed system (e.g., bed rails). Bed rails are beneficial, but misuse can place patients at significant risk. Publication Date: 12-01-2006 Confirming Feeding Tube Placement: Old Habits Die HardDescription: Clinicians can avoid less reliable methods to confirm feeding tube placement in favor of evidence-based methods. Risk reduction strategies may help guide clinicians in minimizing feeding tube misplacement. Publication Date: 12-01-2006 Skin Tears: The Clinical ChallengeDescription: Skin tears are painful, disfiguring injuries, but are preventable. Identification of risk factors, implementation of prevention strategies, and standardizing assessment and treatment can reduce the incidence of skin tears. Publication Date: 09-01-2006 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 Is CT a High-Risk Area for Patient Transport?Description: Emergent patient situations occurring in relation to patient transfer for computed tomography suggest the need for systems to expedite emergency response. Publication Date: 09-01-2005 Early Discharge from the EDDescription: Event reports discuss patients who were discharged too soon after presenting to the emergency department with poisoning, perhaps due to cognitive bias on the part of clinicians. 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 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 |
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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 Emergency Crash Cart Checklist (2010)Description: Facilities may find this sample checklist for the crash cart useful to ensure that the emergency supplies and equipment are periodically monitored and evaluated. Publication Date: 06-01-2010 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 Behavioral Health Patient Room: Common HazardsDescription: This interactive graphic illustrates objects or structure in patient rooms that have contributed to patient harm, according to reports submitted through PA-PSRS. Publication Date: 09-01-2007 Bed Rail Entrapment VideoDescription: This educational video addressess bed rail entrapment, including the benefits and risks of bed rails, entrapment risk factors, and risk reduction strategies. Publication Date: 12-01-2006 Straight A's to Prevent Bed Rail EntrapmentDescription: This poster illustrates the seven zones of bed entrapment and discusses the requisite approach, assessment, actions, and awareness to prevent entrapment. Publication Date: 12-01-2006 Sample Policy on Skin Tear ManagementDescription: This sample policy can be adapted by facilities to provide for comprehensive management of skin tear trauma. Publication Date: 09-01-2006 The Challenge of Skin TearsDescription: This poster illustrates different categories of skin tears and discusses prevention strategies and treatment. Publication Date: 09-01-2006 Sample Policy on Skin Tear PreventionDescription: This sample policy can be adapted by facilities to provide for comprehensive, preventative skin care to patients, especially those susceptible to skin tear trauma. Publication Date: 09-01-2006 The Challenge of Skin Tears in Acute CareDescription: This educational video addresses skin tears in acute care, including risk factors, preventive measures, assessment, categories, and management of injury. Publication Date: 09-01-2006 |
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