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Patient Safety Authority
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Phone: 717-346-0469
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Advisory Banner
December 2005 Patient Safety Advisory 
Complete Issue
December 2005, Vol. 2, No. 4 
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Developing a Culture of Safety
Articles in the medical literature provide insight into the issues surrounding the development of a culture of safety.
Unanticipated Care After Discharge from Ambulatory Surgical Facilities
Patients’ short stays at ambulatory surgical facilities increase the importance of the discharge instructions we provide patients.
Letter to the Editor: PCA by Proxy
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.
Letter to the Editor: Automated Dispensing Cabinets
A pharmacy director comments on an article about automated dispensing cabinets.
Stress Management in Response to Practice Errors: Critical Events in Professional Practice
Critical incident stress management programs can help healthcare personnel cope with the stress of being involved in patient injuries.
Brevity is the Soul of Wit, but Not of Safety
Understanding of events, such as overdose of morphine by means of patient-controlled analgesia, is only possible through thorough event reporting.
The Beers Criteria: Screening for Potentially Inappropriate Medications in the Elderly
Criteria to help practitioners reduce the risk of patient harm by guiding appropriate drug selection for elderly patients are known as the Beers Criteria.
IHI Offers Patient Safety Leadership Guide
The Institute for Healthcare Improvement offers a leadership guide that outlines eight steps healthcare leaders can use to improve safety in their organizations.
From the Mouths of Babes: Healthcare Supplies and Environment Pose Dangers to Children
Event reports suggest that supplies common to the healthcare environment can pose the same risk to young children as small food items and toys.
Study Finds Noncompliance with Drug Black Box Warnings is Common
High-risk medications are frequently prescribed in ways that do not comply with the label warnings.
Emergency Department Management of the Suicidal Patient
Safe care for suicidal patients in emergent situations involves a patient search process, checking the environment for potential hazards, and being alert for elopements.
The Highly Reliable Operating Team
Notes from a panel discussion of the American College of Surgeons convey how surgeons can improve the safety of the operating team.
Continuous Care Throughout Patient Transfer
Distinct patterns have emerged from event reports related to intrahospital transfers, including equipment availability, communication, staff deployment, and readiness to support patients' needs.
Workarounds: A Sign of Opportunity Knocking
While a workaround provides a temporary solution to an immediate problem, it is also a symptom of a system that may need improvement.
Clear Liquids May Place Patients at Risk
Healthcare workers and patients can confuse clear liquids with other products.
 
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