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- Communication Improvement 7
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 4
- Human Factors Engineering 4
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Specialization of Care 1
- Teamwork 3
- Technologic Approaches 3
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 5
- Interruptions and distractions 1
- Medical Complications 2
- Medication Safety 2
- Surgical Complications 7
Search results for "State Governments and Agencies"
- State Governments and Agencies
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.
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.
Journal Article > Study
Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors.
Shea JA, Willett LL, Borman KR, et al. Acad Med. 2012;87:895-903.
Conducted before implementation of the 2011 ACGME duty hour limits, this survey found that the majority of internal medicine and surgery program directors believed the new regulations would negatively affect the learning environment and continuity of care, as well as result in increased faculty workload and require changes in clinical services.
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.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
Journal Article > Study
Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.
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.
Tools/Toolkit > Multi-use Website
Washington State Hospital Association.
This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.
PA-PSRS Patient Saf Advis. December 2007;4:109, 112-123.
This article summarizes a state-level analysis that used site visits along with near miss and error reports to evaluate wrong-site surgeries.
PA-PSRS Patient Saf Advis. June 2007;4:29, 32-45.
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggestions to reduce this type of error.
Special or Theme Issue
Expert panel on weight loss surgery. Betsy Lehman Center for Patient Safety and Medical Error Reduction. Evidence-based recommendations for best practices in weight loss surgery.
Obes Res. 2005;13: 203-305.
A report from an expert panel convened to study surgical weight loss programs and procedures from a patient safety perspective. Relevant literature was collected and reviewed to provide evidence-based recommendations.