The Patient Safety Authority administrator discusses the growth of the Patient Safety Advisory with each successive issue and encourages Pennsylvania healthcare facilities to continue to use the Advisory and other associated resources to improve patient safety.

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.

John R. Clarke, M.D., Clinical Director of PA-PSRS, invites providers who perform colonoscopies to participate in a statewide safety initiative to reduce the risk of colon perforations during colonoscopy.

Clinicians who use alcohol-based hand sanitizers in oxygen-enriched environments (e.g., operating rooms) can engage in safe practices to reduce the risk of fire.

An invited specialist comments on purple glove syndrome, an adverse drug reaction related to intravenous administration of phenytoin (DILANTIN).

Toxic anterior segment syndrome (TASS) is a rare complication of intraocular surgery that can nevertheless cause permanent injury to the eye.

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.

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.

Heparin is a high-alert medication that warrants unique handing during prescripting, dispensing, and administration.