Event reports submitted through PA-PSRS drive the publication of individual Advisory articles that suggest clinical protocols facilities can implement to prevent the occurrence of similar events.

Following safe practices on verbal orders may help reduce the risk of misinterpretation.

Misunderstanding of abbreviations is a frequent happenstance; these examples relate to medication orders.

Errors in catheter selection or misconnections with other tubings can compromise patient safety.

A Patient Safety Officer shares a case study about nonradiopaque sponges and the lessons they learned from it.

Exposed victims and healthcare workers may not realize the seriousness of exposure to hydrofluoric acid because of the initial benign appearance of symptoms.

A cornea implantation that potentially came from a donor with hepatitis B prompted one hospital to identify and adopt new procedures for tissue handling.

Considering Demerol's potential to stimulate seizures, its effect on the central nervous system, and its anticholinergic effect, this drug may not be the optimal analgesic for treating pain.

These drugs continue to be mistaken for one another due to similar names and are frequently stored next to each other on pharmacy shelves.

Staff from behavioral health hospitals have expressed difficulty identifying events reportable to PA-PSRS due to the uniqueness of their clinical setting.

This is the June 2006 issue of the Patient Safety Advisory.