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Patient Safety Authority
333 Market Street
Lobby Level
Harrisburg, PA 17120


Phone: 717-346-0469
Fax: 717-346-1090


 
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Saves, System Improvements, and Safety-II
Pa Pat Saf Advis 2016 Dec;13(4):171. 
 

“Saves, System Improvements, and Safety-II” is an occasional feature of the Pennsylvania Patient Safety Advisory, highlighting successes of healthcare workers in keeping patients safe. The Safety-II approach assumes that everyday performance variability provides adaptations needed to respond to varying conditions and that humans are a resource for system flexibility and resilience.

Exceeding “Routine” Checks of AEDs

A healthcare worker completing routine checks on an AED (automated external defibrillator) noted that the defibrillation electrodes (pads) in the emergency cart were not compatible with the AED. Further investigation revealed that multiple AEDs throughout the facility were affected. The correct pads were ordered and installed.

AEDs may be needed in emergencies when seconds count and delays in treatment can contribute to poor neurologic outcomes or even death. Imagine discovering an equipment mismatch in the middle of a resuscitation and having to scramble to find the right parts. Even though this healthcare worker was completing a routine—perhaps even a mundane—task, he or she went beyond just “checking the box” that all of the necessary parts were available and made sure that all of the parts fit together correctly. This person even went a step further, recognized that this mismatch could affect more than one AED, and checked on the other similar devices throughout the facility. These actions helped to ensure that if an AED were needed for an emergency anywhere in the facility, it would be fully functional.

 
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THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS  
PSA LOGO The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .      
ECRI LOGO ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.      

ISMP Logo The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.      
 
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