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- Communication between Providers 12
- Culture of Safety 3
- Education and Training 7
- Error Reporting and Analysis 12
- Human Factors Engineering 9
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 10
- Specialization of Care 4
- Teamwork 3
- Clinical Information Systems 2
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 5
- Identification Errors 4
- Interruptions and distractions 1
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 11
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 1
- Surgical Complications 3
- Health Care Executives and Administrators 28
Health Care Providers
- Nurses 4
Non-Health Care Professionals
- Media 1
- Patients 2
Search results for "State Governments and Agencies"
- Newspaper/Magazine Article
- State Governments and Agencies
Field C, Finley E, Deutsch ES. PA-PSRS Pa Patient Saf Advis. 2019;16(1).
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45.
Feil M. PA-PSRS Patient Saf Advis. June 2014;11:45-52.
Operating rooms are complex environments with particular risks regarding interruptions and distractions. This article draws from data reported to the Patient Safety Authority to explore how distractions affect surgeons and other team members. The author reviews strategies to limit distractions, including applying sterile cockpit principles, performing preoperative briefings, and utilizing checklists.
Munn J. PA-PSRS Patient Saf Advis. March 2014;11:23-29.
Patients are increasingly being asked to assume a role in ensuring their own safety. This report explores patients' adoption of practices meant to help improve their safety and found that 8 of the 10 suggested tactics are actively used by health care consumers in Pennsylvania.
Gao T, Gaunt MJ. PA-PSRS Patient Saf Advis. December 2013;10:125-136.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies problems related to the medication reconciliation process and includes methods to address them.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
Sparnon E. PA-PSRS Patient Saf Advis. September 2013;10:92-95.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this article reviews the unintended consequences of automated default values, including errors in the electronic medical record and medication administration delays.
Feil M. PA-PSRS Patient Saf Advis. March 2013;10:1-10.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece outlines the types of distractions that contribute to medical errors and recommends strategies to mitigate them.
PA-PSRS Patient Saf Advis. September 2011;8:85-93.
Analyzing reports of medication errors in ambulatory surgery centers, this article discusses common error types and provides suggestions to prevent such events and prioritize improvement efforts.
PA-PSRS Patient Saf Advis. June 2011;8:63-69.
Exploring causes of wrong-site, wrong patient, and wrong procedure errors in radiology, this piece suggests strategies to reduce the incidence of such events.
PA-PSRS Patient Saf Advis. March 2011;8:1-7.
This piece reports on the prevalence of medication errors in the emergency department and suggests expanding pharmacy involvement as a strategy to reduce risks.
PA-PSRS Patient Saf Advis. 2010;7:123-134.
This report examines how optimizing patient flow from emergency department arrival to diagnosis can enhance quality and safety.
PA-PSRS Patient Saf Advis. September 2010;7:76-86.
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.
PA-PSRS Patient Saf Advis. June 2010;7:46-51.
This piece characterizes medication storage methods that contribute to adverse drug events and provides suggestions for improvement.
PA-PSRS Patient Saf Advis. March 2010;7:9-17.
This article analyzed 2685 event reports involving insulin and found that the most common error types were drug omission, wrong-dose, and wrong-drug errors.
PA-PSRS Patient Saf Advis. December 2009;6:109-114.
This article discusses adverse incidents submitted to the Pennsylvania reporting system involving neuromuscular blocking agents and shares strategies to minimize errors with this type of high-alert drug.
PA-PSRS Patient Saf Advis. September 2009;6:93-97.
This article reports on failures surrounding critical test results and describes mechanisms to standardize communication and reduce patient harm.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
PA-PSRS Patient Saf Advis. March 2009;6:16-19.
This article discusses strategies to ensure safe transitions for patients between hospital departments. These strategies include transport team development, use of standardized communication tools, and educational programming for unlicensed health care personnel.