|
|
|
Pennsylvania Patient Safety Authority
|
|
|
|
|
|
|
|
|
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 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 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 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 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 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 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 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 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 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 Mismatching Medical Devices and AccessoriesDescription: Submitted event reports describing injuries to patients from the use of incompatible device parts make evident the need for awareness about compatibility of medical devices and associated accessories that require assembly before use. Publication Date: 03-01-2005 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 Fetal Lacerations Associated with Cesarean SectionDescription: Several interventions may reduce the risk of fetal laceration associated with Cesarean section, including use of blunt instrumentation, moving the uterine wall away from the fetus before incision, and removing abdominal wall retractors before delivery. Publication Date: 12-01-2004 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 |
|
|
|
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 Vacuum Extraction—Don’t Get Sucked In!Description: Following the important steps in this educational poster may help delivering practitioners effect delivery while maximizing both maternal and fetal safety. Publication Date: 12-16-2009 Perinatal Bundle—Vacuum BundleDescription: Using this retrospective chart review tool may help determine if a bundle of interventions for vacuum delivery is consistently implemented and documented. Publication Date: 12-16-2009 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 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 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 |
|
|
|
|
|
|
| |
|
|
| |
|
|
|
|