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Pennsylvania Patient Safety Authority
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Data Snapshot: Maternal ComplicationsDescription: A search of the Pennsylvania Patient Safety Authority's reporting
system database results in identification of 256 reports of maternal
complications causing harm to mothers. Publication Date: 12-16-2009 Beyond the Count: Preventing the Retention of Foreign ObjectsDescription: Surgical counts are intended to prevent the retention of a sponge, sharp, or instrument during a surgical procedure, yet despite the highly regulated nature of the process, discrepancies in the surgical count occur. Publication Date: 06-01-2009 Quarterly Update on the Preventing Wrong-Site Surgery ProjectDescription: Twelve wrong-site surgeries were reported during the first quarter of 2009 (Q1-2009). In this update, analytical commentary accompanies the report accounts to emphasize previously discussed principles of preventing wrong-site surgery. Publication Date: 06-01-2009 Patient Screening and Assessment in Ambulatory Surgical FacilitiesDescription: As the popularity of these facilities continues to grow and increasingly complex procedures are performed, thorough screening, assessment, and preparation of patients prior to surgery is essential to ensure optimal patient outcomes. Publication Date: 03-01-2009 Data Snapshot: Iatrogenic Burn InjuriesDescription: A recent article in the Wall Street Journal led Authority analysts to query the PA-PSRS database for burn related reports submitted in 2007. Publication Date: 03-01-2009 Editorial: WHO Surgical Safety ChecklistDescription: The Second Global Patient Safety Challenge: Safe Surgery Saves Lives initiative introduced this checklist, designed to catch omissions in the actions supporting an operation before the patient suffers harm. Publication Date: 09-01-2008 Rapid Response in the Operating RoomDescription: Rapid response teams have proven effective for hospitalized patients in distress outside of critical care areas. Publication Date: 09-01-2008 Forcing Functions of Antibiotic ProphylaxisDescription: Introducing certain forcing functions can help improve physician behavior associated with use of prophylactic antibiotics in preventing surgical site infections, according to a program undertaken at Temple University Hospital. Publication Date: 09-01-2008 The American College of Surgeons Recommends Sharps Safety PracticesDescription: The American College of Surgeons (ACS) recommends that healthcare facilities adopt certain operating room (OR) work practices to avoid surgeons’ and OR staff members’ exposure to bloodborne infections as a result of sharp injuries and surgical glove tears. Publication Date: 03-01-2008 Letter to the Editor: Surgical Complication IncidenceDescription: The director of surgery at a Pennsylvania hospital asks about incidence of surgical complications by day of the week. The Advisory welcomes letters to the editor, either in response to previous published articles or as questions or comments or alternative opinions consistent with the objectives of the Advisory Publication Date: 03-01-2008 Insight into Preventing Wrong-Site SurgeryDescription: Incidence of wrong-site surgery has decreased in Pennsylvania, but PA-PSRS continues to receive reports of its occurrence. PA-PSRS’s analysis suggests opportunities for wrong-site surgery prevention. Publication Date: 12-01-2007 Reducing Complications from Interscalene BlocksDescription: An interscalene block (ISB) is an effective anesthetic technique with many advantages, but it is associated with certain complications, such as seizure and arrhythmia. Implementing specific risk reduction strategies before, during, and after ISB may help patients realize the benefits of ISB without the associated complications. Publication Date: 12-01-2007 Query on Wrong-Site SurgeryDescription: A reader questions whether the analysis of wrong-site surgery events reported in Pennsylvania and the resulting article adequately addresses the responsibility of physicians in preventing wrong-site surgery. Publication Date: 09-01-2007 Preventing Adverse Events Related to Chest Tube InsertionDescription: A tutorial program for physicians that discusses four sources of adverse outcomes during chest tube insertion (e.g., incorrect surgical technique) is available from the U.S. Agency for Healthcare Research and Quality. Examples of these sources of adverse outcomes are apparent in reports to PA-PSRS. Publication Date: 09-01-2007 Deaths Following Ambulatory SurgeryDescription: Analysis of reports of patient deaths following ambulatory surgery emphasizes the need for ambulatory surgical facilities to be able to respond to emergency conditions. Publication Date: 09-01-2007 Doing the Right Things to Correct Wrong-Site SurgeryDescription: Wrong-site surgery that touches the patient is expected to occur once a year in the operating room of a 300-bed hospital. Considering wrong-site surgery prevention processes as a whole is an important strategy to preventing wrong-site surgery. Publication Date: 06-01-2007 Airway Fires during SurgeryDescription: Following safe practices can help reduce the likeliness of fires during airway surgery that involves ignition sources such as electrosurgical units. Publication Date: 03-31-2007 Perforations of the Colon during ColonoscopiesDescription: 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. Publication Date: 12-01-2006 Confirming Feeding Tube Placement: Old Habits Die HardDescription: 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. Publication Date: 12-01-2006 Bone Cement Implantation SyndromeDescription: 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. Publication Date: 12-01-2006 Delays in the OR: Stress Between "Running Two Rooms" and "Time Outs"Description: 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. Publication Date: 09-01-2006 Abbreviation GotchasDescription: Misunderstanding of abbreviations is a frequent happenstance; these examples relate to medication orders. Publication Date: 06-01-2006 Threat of Cornea Transplant ContaminationDescription: A cornea implantation that potentially came from a donor with hepatitis B prompted one hospital to identify and adopt new procedures for tissue handling. Publication Date: 06-01-2006 Demerol: Is It the Best Analgesic?Description: 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. Publication Date: 06-01-2006 Bioburden on Surgical InstrumentsDescription: Reports of soiled instruments contaminating surgical fields emphasize the importance of performing quality control on each step of equipment preparation: cleaning, disinfecting, and sterilizing. Publication Date: 03-01-2006 Electrosurgery Safety IssuesDescription: More than half of electrosurgery unit- (ESU-) related burns and fires are attributable to inadvertent ESU activation, which is easily prevented. Publication Date: 03-01-2006 The Highly Reliable Operating TeamDescription: Notes from a panel discussion of the American College of Surgeons convey how surgeons can improve the safety of the operating team. Publication Date: 12-01-2005 Update on Alcohol-Based Surgical Prep SolutionsDescription: Since publication of the June 2005 Patient Safety Advisory article "Risk of Fire from Alcohol-Based Solutions," the National Fire Protection Association amended its standards to permit the use of flammable liquid germicides provided specific precautions are followed. Publication Date: 09-01-2005 Lost Surgical Specimens, Lost OpportunitiesDescription: The substantial increase in the volume of ambulatory surgical procedures increases the need to prepare for delivering unanticipated patient care and safe transfers to hospitals. Publication Date: 09-01-2005 PA-PSRS Pointers: Avoiding Betadine BurnsDescription: Skin irritation and severe skin reactions may occur when wet, unevaporated Betadine solution comes in prolonged contact with the skin. Publication Date: 06-01-2005 Multiple Messages, Multiple TasksDescription: After an event is determined to be the result of ineffective communication, two salient points include (1) fewer intermediaries create fewer opportunities for misunderstanding and (2) the less that intermediaries understand about the message, the greater the chance for misunderstanding. Publication Date: 03-01-2005 Mismatching Medical Devices and AccessoriesDescription: Submitted event reports describing injuries to patients from the use of incompatible device parts make evident the need for awareness about compatibility of medical devices and associated accessories that require assembly before use. Publication Date: 03-01-2005 Risk of Unnecessary Gall Bladder SurgeryDescription: Event reports discuss attempted cholecystectomy procedures in patients who had previously had their gall bladders removed; these previous procedures did not become known until the patients' surgeries were performed. Publication Date: 12-01-2004 Follow-up on Previous Advisory ArticlesDescription: Patient Safety Officers share feedback and follow-up on two topics of previous Advisory issues (i.e., insulin and tuberculin syringe confusion, time out processes). Publication Date: 12-01-2004 A Rare but Potentially Fatal Complication of ColonoscopyDescription: If a healthcare team has a high index of suspicion of splenic injury in patients who develop abdominal symptoms after colonoscopy, successful outcomes from this rare complication are more likely to occur. Publication Date: 12-01-2004 Use of Checklists in Complex EnvironmentsDescription: Reminders are an essential part of monitoring activities in complex environments such as healthcare. Incorporating checklists as reminders into the healthcare environment can yield beneficial results, such as improved compliance with best practices in clinical settings. Publication Date: 09-01-2004 Two Takes on the Time OutDescription: Event reports demonstrate (1) that the time out can be useful defense against wrong-site surgery and (2) problems with implementing the time out may limit its benefits. Publication Date: 09-01-2004 Hidden Sources of Latex in Healthcare ProductsDescription: Latex exposure and allergic reactions continue to occur. It is important for healthcare providers to recognize latex-containing products and use suitable alternatives in situations that call for them. Publication Date: 06-01-2004 Problems Related to Informed ConsentDescription: Excluding emergency or otherwise problematic cases, the commonly reported problem related to informed consent involved cases in which patients received several procedures during the same episode of care and consented to some procedures but not to others. Publication Date: 06-01-2004 Patient IdentificationDescription: The potential for errors of patient identification may be greatest in acute care hospitals, where a wide range of interventions are delivered in various locations by numerous staff who work in shifts. Publication Date: 06-01-2004 |
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Wrong Spinal Level Analysis FormDescription: This form is an addendum to the "Wrong-Site/-Side Surgery Error Analysis Form" and should complement the main form, as applicable. Publication Date: 12-01-2009 Principles for Reliable Performance of Correct-Site SurgeryDescription: If surgical facilities are to hold their gains in consistently performing correct-site surgery, these principles for reliable performance of correct-site surgery, identified by the Pennsylvania Patient Safety Authority during its Preventing Wrong-Site Surgery Project, should be consistently followed. Publication Date: 09-01-2009 Table 2. Marking Experiences Listed by Skin Preparation AgentsDescription: The Pennsylvania Patient Safety Authority surveyed operating room managers about their experiences with using various marking pens with various skin preparation agents. The following table lists experiences according to skin preparation agents. Publication Date: 09-01-2009 Table 1. Marking Experiences Listed by MarkersDescription: The Pennsylvania Patient Safety Authority surveyed operating room managers about their experiences with using various marking pens with various skin preparation agents. The following table lists experiences according to markers. Publication Date: 09-01-2009 Retained Foreign Object Audit FormDescription: This sample form may be used for auditing events involving the unintentional retention of a foreign object. Publication Date: 06-01-2009 Time-Out in the OR CompetitionDescription: Script entries for the Authority's Time-Out in the OR Competition are depicted here. Publication Date: 03-01-2009 Health HistoryDescription: This sample form may be sent to the primary care physician or the referring physician for completion before the day of surgery. This form may be reviewed by anesthesia and nursing staff before the day of surgery, according to facility policy and procedures. Publication Date: 03-01-2009 Nursing Preoperative ScreeningDescription: This sample form may be used for nursing preadmission before the day of surgery. This form may be used for telephone or in-person screening and modified per facility policy and procedure. Publication Date: 03-01-2009 How Can You Prevent Wrong-Site Surgery?Description: Surgeons or facilities can give this brochure to preoperative patients so that they understand why so many providers ask the same questions. Facility-specific logos or contact information can be added to personalize the brochure. Publication Date: 12-01-2008 Wrong-Site/-Side Surgery Error Analysis FormDescription: Anyone faced with a wrong-site surgery near miss or occurrence in his or her facility is encouraged to use this form to aid in the analysis. Publication Date: 12-01-2008 OR Scheduling FormDescription: This sample form includes suggested elements pertinent to scheduling cases for the operating room. Publication Date: 06-01-2008 Day of Surgery: Standardized Independent Verification 1Description: This sample verification form includes elements pertinent to verifying patient information, medical documentation, and surgical information. It has been suggested that two independent healthcare providers independently verify the information and documentation before the start of the procedure. Publication Date: 06-01-2008 Preoperative ChecklistDescription: This sample checklist includes suggested elements pertinent to checking patient information, medical documentation, and surgical information. Publication Date: 06-01-2008 Day of Surgery: Standardized Independent Verification 2Description: This sample verification form includes elements pertinent to verifying patient information, medical documentation, and surgical information. It has been suggested that two independent healthcare providers independently verify the information and documentation before the start of the procedure. Publication Date: 06-01-2008 The Awareness of Information in the Operating RoomDescription: his figure discusses the awareness of information in the operating room, including information from the schedule, medical record, and consent, as well as patient input. Publication Date: 12-01-2007 Obstructive Sleep Apnea Preoperative Screening ToolDescription: This sample questionnaire is not a substitute for a sleep disorder evaluation by a qualified physician, but it may help identify at-risk patients during the preoperative period. Publication Date: 09-01-2007 Airway Fires during SurgeryDescription: Airway surgeries that involve ignition sources to cut or coagulate tissue pose a significant and sometimes deadly risk of fire. This poster discusses ways to minimize and fight airway fires. Publication Date: 03-01-2007 |
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Know Your Medical HistoryDescription: Patients who do know their full medical history are at increased risk to receive unecessary surgery or medical care. Publication Date: 03-01-2008 Wrong Site Surgery Consumer TipsDescription: Wrong-site surgeries are 100 percent preventable, and patients or their family members can help prevent such errors by speaking up. Publication Date: 06-27-2007 |
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