The Patient Safety Authority receives the Joint Commission award in acknowledgement of the Authority's impact on patient safety on a regional level because of efforts to develop nationally recognized resource.

Skin tears are painful, disfiguring injuries, but are preventable. Identification of risk factors, implementation of prevention strategies, and standardizing assessment and treatment can reduce the incidence of skin tears.

A reader comments on the use of propofol for procedural sedation in the emergency department.

Readers compliment work-to-date in Pennsylvania on color-coded wristbands, recommend consideration of isolation patients, and raise the question of nationwide standardization.

A reader comments on the presence of metal shot in MRI sandbags.

Sandbags containing metal pellets present an MRI hazard.

Understanding the causes of medication errors requires focusing on the medication use system (e.g., obtaining patient information, communicating drug orders).

While there are many, often unavoidable reasons for delays in the operating room, addressing scheduling, transfer of care, case notification, and delays while patients are under anesthesia can help minimize the risk of procedure delays.

A physician reporting model, DISCLOSE, addresses barriers to physician reporting.

When used in error, epinephrine poses a greater risk of harm and death than other drugs. The majority of epinephrine errors involve ratio strength and look-alike names (epinephrine and ephedrine).

Foil backing on transdermal medication patches may cause tissue burns during MRI.

Certain letters and numerals (lower case letter "l" and number 1) can be interpreted different than the writer intended in medication orders, potentially resulting in medication errors.

Facilities may be missing opportunities to improve quality of care if they fail to assess patients for risk of developing pressure ulcers and fail to collect information about stages of any pressure ulcers that develop.

Criteria from the American College of Radiology address diagnostic imaging studies for patients with suspected small bowel obstruction.

Disruptive behavior from nurses, physicians, and hospital administrators can put patients at risk.