Pennsylvania State Authority Advises on Patient Safety
MedSun: Newsletter #4, May 2006

The Pennsylvania State Patient Safety Authority, an independent State agency, presents evidence in its recently issued Annual Report for 2005 that mandatory reporting of adverse events and subsequent clinical guidance on avoiding such events in the future make significant contributions to promoting and improving patient safety. The first full year of statewide mandatory reporting yielded close to 175,000 reports, most of them not qualifying as serious events. Based on these reports, the Authority published more than 60 scholarly articles in its quarterly Patient Safety Advisory, a journal that provides guidance to facilities about promoting patient safety and reducing the potential for medical error.

Some of the changes that have been instituted in hospitals and ambulatory surgical facilities as a result of Advisory articles include the following:

•Reducing the number of color-coded patient wristbands in use in facilities;
•Minimizing the risk of alcohol-based fires by using towels to catch alcohol runoff in operating rooms;
•Educating surgeons about the importance of “time out” before surgery, in which the patient’s identity and other critical elements of the planned procedure are reviewed;
•Adding to providers’ list of prohibited abbreviations, based on potentially confusing abbreviations identified in the Advisory; and
•Educating staff on how to minimize the risk of anesthesia awareness.

Additional Information:

Pennsylvania’s Patient Safety Authority

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