John R. Clarke, MD, editor, discusses this subtle yet important difference in achieving consistently good patient care systemwide.

Following safe practices can help reduce the likeliness of fires during airway surgery that involves ignition sources such as electrosurgical units.

A reader questions the efficacy of alcohol-based hand rubs in preventing the transmission of C. difficile.

In December 2006 and January 2007, the Pennsylvania Patient Safety Authority hosted discussion groups of Patient Safety Officers. A full report on the discussions is available.

In the December 2006 PA-PSRS Patient Safety Advisory, a sentence in the article “Bone Cement Implantation Syndrome” omitted a key phrase.

Longstanding familiarity with promethazine may mask its potential for patient harm, such as severe tissue damage, if not administered cautiously with proper patient monitoring.

An event report includes an example of an abbreviation, HCT, that caused a patient to receive an unintended intervention.

Incidence of PA-PSRS reports following documented problems related to the Colleague series pumps suggests that efforts to address these problems may not have reached all clinical settings or facilities and that additional awareness may help reduce some infusion pump failures.

Two recently discovered MRI hazards and related safety strategies are discussed.

Accidental injection of oral nimodipine for patients unable to swallow may result in severe hypotension, cardiovascular collapse, or cardiac arrest.

PA-PSRS has received reports of complications of retrobulbar blocks, including central nervous system spread of anesthesia, retrobulbar hemorrhages, respiratory arrest, and death, despite the declining use of this technique in favor of topical anesthetics.

An online educational program, "Get the Facts on Toxic Anterior Segment Syndrome," is available about the etiology of and care and treatment for TASS.

Understanding the potential risks associated with electroconvulsive therapy will help promote a safe treatment outcome.