At the one-year anniversary mark of PA-PSRS, discussion centers on how the program has improved patient safety in Pennsylvania.

Several C. diff-related deaths in Pennsylvania highlight the need for medical intervention for evaluation and early treatment of C. diff-associated disease to occur more rapidly.

Skin irritation and severe skin reactions may occur when wet, unevaporated Betadine solution comes in prolonged contact with the skin.

While the Five Rights are essential goals of medication administration, they do not address the human factors and systems-related causes of errors.

Event reports describe cases in which patients' eyelids were inadvertently glued shut while Dermabond was applied to facial lacerations.

Lessons learned from an Anonymous Report filed under Act 13 include agreements about the definition of a Serious Event, event reporting, and peer review of potentially reportable events.

While flammable liquid germicides are good antimicrobial agents, their misuse can present a significant fire hazard.

Look-alike packaging and embossed labeling may contribute to medication errors with respiratory medications.

Experiences of Pennsylvania facilities’, conveyed through event reports, include suggestions to minimize the potential for a procedure to begin without a time out and actions to help prevent occurrence of retained foreign bodies.

An event report about insulin and tuberculin syringe confusion prompts revisiting this topic, which was first highlighted in the October 28, 2004, supplementary Advisory.

Simple, practical tips developed by clinicians may help to reduce the systemic problem of tourniquets left on patients.

The most frequently cited procedures and sites involved with unintended lacerations or punctures during surgery are identified.

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.

Event reports indicated that patients have sustained skin integrity injuries during pulse oximetry, including discolorations, blisters, lacerations, burns, and necrosis.

Nearly 16% of Serious Events submitted through PA-PSRS involved the use of insulin, a high-alert medication.