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Retained Surgical Items: Events and Guidelines Revisited
left behind were classified into the following related categories using a taxonomy ... a broken needle or screw fragment is recognized at the time of surgery and a clinical judgment is made to leave the ... A retained sponge after a vaginal delivery is a reviewable sentinel event. The new language in the definition of reviewable sentinel
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Opioid Knowledge Self-Assessment
patientsafety.pa.govOpioid Knowledge Self-Assessment Healthcare facilities can use this assessment for practitioners who prescribe, dispense, and/or administer opioid products ...
Letter to the Editor: Preventing Air Embolism with PICC ...
patientsafety.pa.govletter to the editor: preventing air embolism with picc line removal I read with interest your article “Reducing Risk of Air Embolism Associated with Central Venous Access Devices” in the Pennsyl-
Strategic Plan 2017-2020 - Patient Safety Authority
patientsafety.pa.govStrategic Plan During 2016, the Pennsylvania Patient Safety Authority Board of Directors and staff engaged in a third strate- ... Strategic Plan 2017–2020 VISION Safe healthcare for all patients MISSION Improve the quality of healthcare in Pennsylvania by collecting and
PATIENT SAFETY: COLOR BANDING Standardization and ...
patientsafety.pa.govColor-banding policy will need to be reviewed and approved. Hospitals need to review their respective forms for need of modifications (pt. ed, assessments, etc.) ... • Color Code – Intent of Specific Colors • Authority for Application of band • Process for Band Confirmation • Inter-Dept./Agency Communication
Treating Hyperkalemia: Avoid Additional Harm When …
patientsafety.pa.govAn order received in pharmacy at 2000 read "If K+ [potassium] 3.5 [lower limit of normal range] then give K-Lyte [potassium bicarbonate and potassium chloride; to treat low potassium levels] 50 mEq via peg tube BID x 1 day."
Confirming Feeding Tube Placement: Old Habits Die Hard
patientsafety.pa.govMore Reliable Methods to Verify Feeding Tube Placement Radiographic Confirmation of Nasogastric Tube Placement The gold standard for nasogastric feeding tube placement is radiographic confirmation with a chest x-ray. pretations by nonradiologists: The gold standard for nasoenteric feeding tube placement is radiographic confir-
The Beers Criteria: Screening for Potentially ...
patientsafety.pa.govhepatic clearance of many drugs, such as diazepam, amitriptyline, and chlordiazepoxide, carried out by the cytochrome P-450 system often diminishes with age. Overall, the clearance of drugs metabolized by the liver is typically decreased 30 to 40% in the elderly. Renal size and renal blood flow also decrease signifi-cantly with age.
Safety in Using Promethazine (Phenergan)
patientsafety.pa.gov©2007 Pennsylvania Patient Safety Authority Page 1 Produced by ECRI Institute & ISMP under contract to the Patient Safety Authority Patient Safety Advisory F irst approved by the U.S. Food and Drug Ad-ministration (FDA) in 1951, promethazine (Phenergan) is a medication in common use today. However, despite its familiarity, its use is not with-
PATIENT SAFETY AUTHORITY AND DEPARTMENT OF HEALTH
patientsafety.pa.gov12. A mid-procedure change in the plan of care in response to new information discovered during the procedure does not constitute an injury. 13. Additional healthcare services: a. Healthcare services provided to prevent an injury from occurring are excluded from this term for the purpose of Serious Event determinations. b.
Brochure Medical Records - Pennsylvania Patient Safety ...
patientsafety.pa.govrecord. In the future, when medi-cal records are requested by other providers, your provider must include his denial of your request to amend the medical record as well a copy of your statement of disagreement. It should not take more than 90 days to amend your medical records. If the request is accepted,
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