Patient Safety Authority

Patient Safety Authority The Patient Safety Authority is an independent state agency of the Commonwealth of Pennsylvania charged with taking steps to prevent medical errors.
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Operating as usual

07/23/2021

COVID-19 vaccines are still the best way to protect against the virus and its variants. Don't wait—get vaccinated ASAP to protect yourself, your family and others in your community!

We’re now on Instagram! Please follow us at https://www.instagram.com/PatientSafetyAuthority/ for engaging patient safet...
07/22/2021

We’re now on Instagram! Please follow us at https://www.instagram.com/PatientSafetyAuthority/ for engaging patient safety stories, tips, videos, articles, and more. Share our posts, tell your friends, and join us in improving healthcare for everyone.

We’re now on Instagram! Please follow us at https://www.instagram.com/PatientSafetyAuthority/ for engaging patient safety stories, tips, videos, articles, and more. Share our posts, tell your friends, and join us in improving healthcare for everyone.

Do you know a patient safety hero? Tell us about them! Mark your calendar for the 9th Annual I AM Patient Safety (IAPS) ...
07/20/2021

Do you know a patient safety hero? Tell us about them! Mark your calendar for the 9th Annual I AM Patient Safety (IAPS) Awards: The nomination period will be open from October 11–December 10, 2021.

IAPS is an annual contest that recognizes individuals and teams for their commitment to patient safety. Traditionally IAPS has celebrated healthcare workers in Pennsylvania; however, last year we added a nationwide award for an individual, team, or facility outside the Commonwealth that has made an impact. This year we created two new award categories, Sepsis and Time-Out, and in addition to our award winners we will also highlight two runners-up in each category to honor more patient safety heroes for their extraordinary work.
So get your nominations ready and help us celebrate those who are making a difference every day and helping advance safe healthcare for all patients!

For more information about the awards, including this year’s brand-new categories, visit http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS_2022_homepage.aspx.

Do you know a patient safety hero? Tell us about them! Mark your calendar for the 9th Annual I AM Patient Safety (IAPS) Awards: The nomination period will be open from October 11–December 10, 2021.

IAPS is an annual contest that recognizes individuals and teams for their commitment to patient safety. Traditionally IAPS has celebrated healthcare workers in Pennsylvania; however, last year we added a nationwide award for an individual, team, or facility outside the Commonwealth that has made an impact. This year we created two new award categories, Sepsis and Time-Out, and in addition to our award winners we will also highlight two runners-up in each category to honor more patient safety heroes for their extraordinary work.
So get your nominations ready and help us celebrate those who are making a difference every day and helping advance safe healthcare for all patients!

For more information about the awards, including this year’s brand-new categories, visit http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS_2022_homepage.aspx.

FINAL CALL! Manuscripts for the special pharmacy issue of PATIENT SAFETY are due tonight (7/19/21) at 11:59 p.m. ET. Sub...
07/19/2021

FINAL CALL! Manuscripts for the special pharmacy issue of PATIENT SAFETY are due tonight (7/19/21) at 11:59 p.m. ET. Submit them at patientsafetyj.com or email [email protected].

FINAL CALL! Manuscripts for the special pharmacy issue of PATIENT SAFETY are due tonight (7/19/21) at 11:59 p.m. ET. Submit them at patientsafetyj.com or email [email protected].

Infectious disease epidemiologist Dr. Steffanie Strathdee and her husband, Tom Patterson, an evolutionary biologist, lov...
07/16/2021

Infectious disease epidemiologist Dr. Steffanie Strathdee and her husband, Tom Patterson, an evolutionary biologist, loved adventuring together. They went all over the world, wherever their work took them—no matter how risky or remote the locale. But on one vacation to Egypt, they got more than they bargained for when Tom got sick. Really sick.

He was diagnosed with a superbug, a bacteria that has become resistant to the antibiotic drugs designed to kill them. In fact, the bug Tom caught was the worst of the lot, topping the World Health Organization’s “Dirty Dozen” of the most serious bacterial threats to human health. With no traditional treatments effective against his infection, Tom’s condition got worse and worse, but Steffanie never gave up searching for a cure. And she finally found one: bacteriophage therapy,
which uses viruses called “phages” that only kill bacteria.

Phage therapy, in conjunction with antibiotics and other experimental treatments, offers hope to patients with superbug infections who may have run out of other options, a problem that will only grow as more bacteria develop resistance to antibiotics. Steffanie and Tom’s story is a powerful reminder of how patients and their families can be their own advocates, as well as the importance of careful antibiotic stewardship and research into innovative treatments and therapies.

Read the interview at https://patientsafetyj.com/index.php/patientsaf/article/view/steffanie-strathdee-interview

Infectious disease epidemiologist Dr. Steffanie Strathdee and her husband, Tom Patterson, an evolutionary biologist, loved adventuring together. They went all over the world, wherever their work took them—no matter how risky or remote the locale. But on one vacation to Egypt, they got more than they bargained for when Tom got sick. Really sick.

He was diagnosed with a superbug, a bacteria that has become resistant to the antibiotic drugs designed to kill them. In fact, the bug Tom caught was the worst of the lot, topping the World Health Organization’s “Dirty Dozen” of the most serious bacterial threats to human health. With no traditional treatments effective against his infection, Tom’s condition got worse and worse, but Steffanie never gave up searching for a cure. And she finally found one: bacteriophage therapy,
which uses viruses called “phages” that only kill bacteria.

Phage therapy, in conjunction with antibiotics and other experimental treatments, offers hope to patients with superbug infections who may have run out of other options, a problem that will only grow as more bacteria develop resistance to antibiotics. Steffanie and Tom’s story is a powerful reminder of how patients and their families can be their own advocates, as well as the importance of careful antibiotic stewardship and research into innovative treatments and therapies.

Read the interview at https://patientsafetyj.com/index.php/patientsaf/article/view/steffanie-strathdee-interview

Sarcoma Awareness Month runs throughout July. Sarcomas are rare cancers that develop in muscle, bone, nerves, cartilage,...
07/15/2021

Sarcoma Awareness Month runs throughout July. Sarcomas are rare cancers that develop in muscle, bone, nerves, cartilage, tendons, blood vessels, and fatty fibrous tissues. There are more than 70 types of #sarcoma. Learn more: https://www.mayoclinic.org/diseases-conditions/sarcoma/symptoms-causes/syc-20351048

Sarcoma Awareness Month runs throughout July. Sarcomas are rare cancers that develop in muscle, bone, nerves, cartilage, tendons, blood vessels, and fatty fibrous tissues. There are more than 70 types of #sarcoma. Learn more: https://www.mayoclinic.org/diseases-conditions/sarcoma/symptoms-causes/syc-20351048

July is Ultraviolet (UV) Safety Month. UV rays can damage skin in as little as 15 minutes. Reduce your risk by seeking s...
07/14/2021

July is Ultraviolet (UV) Safety Month. UV rays can damage skin in as little as 15 minutes. Reduce your risk by seeking shade and wearing long-sleeved shirts, long pants or skirts, a hat with a brim, and sunglasses. Don’t forget to put on sunscreen!

Learn sun safety tips: https://www.cdc.gov/cancer/skin/basic_info/sun-safety.htm.

July is Ultraviolet (UV) Safety Month. UV rays can damage skin in as little as 15 minutes. Reduce your risk by seeking shade and wearing long-sleeved shirts, long pants or skirts, a hat with a brim, and sunglasses. Don’t forget to put on sunscreen!

Learn sun safety tips: https://www.cdc.gov/cancer/skin/basic_info/sun-safety.htm.

July is National Cleft and Craniofacial Awareness and Prevention Month. Cleft lip and cleft palate are birth defects tha...
07/13/2021

July is National Cleft and Craniofacial Awareness and Prevention Month. Cleft lip and cleft palate are birth defects that occur when a baby’s lip or mouth do not form properly during pregnancy. Children with a craniofacial disorder often have complex needs and may undergo a variety of procedures and therapies and surgeries.

Learn more: https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

July is National Cleft and Craniofacial Awareness and Prevention Month. Cleft lip and cleft palate are birth defects that occur when a baby’s lip or mouth do not form properly during pregnancy. Children with a craniofacial disorder often have complex needs and may undergo a variety of procedures and therapies and surgeries.

Learn more: https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Reminder: Submissions for the special pharmacy issue of PATIENT SAFETY are due in less than a week! Visit https://patien...
07/13/2021

Reminder: Submissions for the special pharmacy issue of PATIENT SAFETY are due in less than a week! Visit https://patientsafetyj.com/ to learn more and submit your manuscript by July 19 or email [email protected] for more info. We look forward to seeing your work!

𝗖𝗔𝗟𝗟 𝗙𝗢𝗥 𝗣𝗔𝗣𝗘𝗥𝗦: Current or recent pharmacy students or faculty members are invited to send us manuscripts to be considered for a special issue of 𝘗𝘢𝘵𝘪𝘦𝘯𝘵 𝘚𝘢𝘧𝘦𝘵𝘺 dedicated to academic pharmacy.

The deadline has been extended to Monday, 𝗝𝘂𝗹𝘆 𝟭𝟵, 𝟮𝟬𝟮𝟭. We welcome submissions from anywhere in the world: original research articles, reviews, commentaries, quality improvement studies, or other manuscripts that will advance patient safety.

Visit 𝗽𝗮𝘁𝗶𝗲𝗻𝘁𝘀𝗮𝗳𝗲𝘁𝘆𝗷.𝗰𝗼𝗺 for more information and to submit a manuscript, or email 𝗽𝗮𝘁𝗶𝗲𝗻𝘁𝘀𝗮𝗳𝗲𝘁𝘆𝗷@𝗽𝗮.𝗴𝗼𝘃.

Blood transfusions can be lifesaving interventions to save the most critical patients, but errors during the process can...
07/12/2021
Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses | Patient Safety

Blood transfusions can be lifesaving interventions to save the most critical patients, but errors during the process can be fatal. The good news is blood transfusion errors are preventable, if you know what risk factors to look for. This prompted researchers to do an in-depth analysis of the root causes of such errors within a health system.

They identified the most common events as incorrect or lack of patient identification, wrong blood given, and incorrect or delayed blood orders. A root cause analysis (RCA) revealed that the most frequent causes included lack of a formal process, communication barriers, and technology barriers. From examining the data, the authors derived recommendations to reduce errors within health systems, focused on standardizing processes, enhancing collaboration and communication, reviewing accessibility of information and resources, and improving education and training.

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/blood-transfusion-errors

Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses Authors Elizabeth A. Lancaster, MHA Lexington Veterans Affairs Health Care System https://orcid.org/0000-0003-2096-9225 Elizabeth K. Rhodus, PhD, OTR/L Lexington Veterans Affairs Health Care System, University of Kentuc...

You’ve probably heard the proverb, “Physician, heal thyself.” But last year cardiac anesthesiologist Dr. Michael Leonard...
07/09/2021

You’ve probably heard the proverb, “Physician, heal thyself.” But last year cardiac anesthesiologist Dr. Michael Leonard learned that is easier said than done, especially where COVID-19 is concerned. In March 2020, just as the pandemic was about to ramp up, he went on one last work trip. He did his best to avoid close contact with other people; however, this was an impossible task in the packed airports and flights home to Colorado.

A few days later, Dr. Leonard realized he’d brought back an unwanted souvenir: a cough and fever. He monitored his vital signs, including his blood oxygen levels. At first his oxygen saturation was normal, in the 95–97% range. When those numbers precipitously dropped to 70% just walking up his driveway, he knew he was in trouble. He drove to the University of Colorado Hospital, unable to breathe and knowing that he needed to be intubated.

He remained in the hospital for three months.

Read about Dr. Leonard’s miraculous recovery, his ongoing path to recovery, and the life lessons he learned from being in an intensive care unit bed rather than beside one: https://patientsafetyj.com/index.php/patientsaf/article/view/critical-care-physician-patient

You’ve probably heard the proverb, “Physician, heal thyself.” But last year cardiac anesthesiologist Dr. Michael Leonard learned that is easier said than done, especially where COVID-19 is concerned. In March 2020, just as the pandemic was about to ramp up, he went on one last work trip. He did his best to avoid close contact with other people; however, this was an impossible task in the packed airports and flights home to Colorado.

A few days later, Dr. Leonard realized he’d brought back an unwanted souvenir: a cough and fever. He monitored his vital signs, including his blood oxygen levels. At first his oxygen saturation was normal, in the 95–97% range. When those numbers precipitously dropped to 70% just walking up his driveway, he knew he was in trouble. He drove to the University of Colorado Hospital, unable to breathe and knowing that he needed to be intubated.

He remained in the hospital for three months.

Read about Dr. Leonard’s miraculous recovery, his ongoing path to recovery, and the life lessons he learned from being in an intensive care unit bed rather than beside one: https://patientsafetyj.com/index.php/patientsaf/article/view/critical-care-physician-patient

𝗖𝗔𝗟𝗟 𝗙𝗢𝗥 𝗣𝗔𝗣𝗘𝗥𝗦: Current or recent pharmacy students or faculty members are invited to send us manuscripts to be conside...
07/08/2021

𝗖𝗔𝗟𝗟 𝗙𝗢𝗥 𝗣𝗔𝗣𝗘𝗥𝗦: Current or recent pharmacy students or faculty members are invited to send us manuscripts to be considered for a special issue of 𝘗𝘢𝘵𝘪𝘦𝘯𝘵 𝘚𝘢𝘧𝘦𝘵𝘺 dedicated to academic pharmacy.

The deadline has been extended to Monday, 𝗝𝘂𝗹𝘆 𝟭𝟵, 𝟮𝟬𝟮𝟭. We welcome submissions from anywhere in the world: original research articles, reviews, commentaries, quality improvement studies, or other manuscripts that will advance patient safety.

Visit 𝗽𝗮𝘁𝗶𝗲𝗻𝘁𝘀𝗮𝗳𝗲𝘁𝘆𝗷.𝗰𝗼𝗺 for more information and to submit a manuscript, or email 𝗽𝗮𝘁𝗶𝗲𝗻𝘁𝘀𝗮𝗳𝗲𝘁𝘆𝗷@𝗽𝗮.𝗴𝗼𝘃.

𝗖𝗔𝗟𝗟 𝗙𝗢𝗥 𝗣𝗔𝗣𝗘𝗥𝗦: Current or recent pharmacy students or faculty members are invited to send us manuscripts to be considered for a special issue of 𝘗𝘢𝘵𝘪𝘦𝘯𝘵 𝘚𝘢𝘧𝘦𝘵𝘺 dedicated to academic pharmacy.

The deadline has been extended to Monday, 𝗝𝘂𝗹𝘆 𝟭𝟵, 𝟮𝟬𝟮𝟭. We welcome submissions from anywhere in the world: original research articles, reviews, commentaries, quality improvement studies, or other manuscripts that will advance patient safety.

Visit 𝗽𝗮𝘁𝗶𝗲𝗻𝘁𝘀𝗮𝗳𝗲𝘁𝘆𝗷.𝗰𝗼𝗺 for more information and to submit a manuscript, or email 𝗽𝗮𝘁𝗶𝗲𝗻𝘁𝘀𝗮𝗳𝗲𝘁𝘆𝗷@𝗽𝗮.𝗴𝗼𝘃.

Did you know it’s International Group B Strep (GBS) Awareness Month? GBS is a bacterial infection passed from mother to ...
07/07/2021

Did you know it’s International Group B Strep (GBS) Awareness Month? GBS is a bacterial infection passed from mother to baby—but anyone can get it. Symptoms are different in newborns compared to older people and can depend on the part of the body that is infected. Learn more: https://www.cdc.gov/groupbstrep/about/index.html.

Did you know it’s International Group B Strep (GBS) Awareness Month? GBS is a bacterial infection passed from mother to baby—but anyone can get it. Symptoms are different in newborns compared to older people and can depend on the part of the body that is infected. Learn more: https://www.cdc.gov/groupbstrep/about/index.html.

So many people have risen to the occasion to care for others over the last year. One of those who answered the call is T...
07/06/2021
Terri Roberts, BSN, RN, CIC, FAPIC

So many people have risen to the occasion to care for others over the last year. One of those who answered the call is Terri Lee Roberts, BSN, RN, CIC, FAPIC, a senior infection preventionist with the Patient Safety Authority. In addition to continuing to support Pennsylvania healthcare facilities in need, she and her husband took in their young grandchildren to keep them safe. Read her story and stories from other Certification Board of Infection Control and Epidemiology, Inc.–certified professionals at https://www.cbic.org/OffNav/Honoring-CIC-and-a-IPC/Story-42.htm.

It was a very hard and very, very sad time last spring and as I reflect, I know I made a difference. I did a lot of infection prevention teaching, I helped get PPE to facilities that were in need, and sometimes I was a shoulder to cry on and that’s OK

In order to improve outcomes for patients with a score greater than 7 on the Irish Health Service’s National Early Warni...
07/05/2021
The Surgical Safety Huddle: A Novel Quality Improvement Patient Safety Initiative | Patient Safety

In order to improve outcomes for patients with a score greater than 7 on the Irish Health Service’s National Early Warning Score (NEWS)—which indicates a high clinical risk requiring urgent or emergency response, a significant factor contributing to cardiac arrests—Cork University Hospital in Ireland introduced a “surgical safety huddle.”

While the safety huddle concept originated in the military and aviation industry to mitigate risk in high-pressure situations, more recently it has been adapted into healthcare practices for managing patient care, emergency department overcrowding, and critical care teams.

This quality improvement initiative, the first to involve a surgical safety huddle in Ireland, brought together a multidisciplinary team to share data and information about their surgical patients as a timely intervention. Using a framework of Situational Awareness for Everyone (SAFE), it provided an opportunity for all participants to speak up and collaborate to proactively assess patients’ condition and coordinate a treatment plan. The goal was to identify the deteriorating perioperative patient early enough to intervene—and results showed success in decreasing the number of poor outcomes for the hospital’s highest-risk patients.

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/surgical-safety-huddle-ireland

The Surgical Safety Huddle: A Novel Quality Improvement Patient Safety Initiative Authors Carolyn Cullinane, Mch Department of General Surgery, Cork University Hospital https://orcid.org/0000-0002-9320-1586 Catharina Healy, BSc Department of General Surgery, Cork University Hospital Mary Doyle, MSc....

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333 Market St
Harrisburg, PA
17101

Opening Hours

Monday 9am - 5pm
Tuesday 9am - 5pm
Wednesday 9am - 5pm
Thursday 9am - 5pm
Friday 9am - 5pm

Telephone

(717) 346-0469

Products

PATIENT SAFETY (online ISSN 2641-4716) —patientsafetyj.com

Pennsylvania Patient Safety Annual Report

Pennsylvania Patient Safety Reporting System - PA-PSRS

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About Us

The Pennsylvania legislature established the Patient Safety Authority in 2002 to provide statewide guidance and support to protect the 47 million patients who entrust Pennsylvania healthcare facilities with their lives each year. Seventeen years later, the Authority still is the only independent state agency of its kind in the United States.

The Authority’s vision is “safe healthcare for all patients,” which it strives to achieve by collecting and analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration.

Pennsylvania Act 13 of 2002, the Medical Care Availability and Reduction of Error (MCARE) Act, requires all state hospitals, ambulatory surgical facilities, birthing centers, and certain abortion facilities to report all incidents of harm, real or potential, to the Authority via the Pennsylvania Patient Safety Reporting System (PA-PSRS), a confidential, online system—the largest event reporting database in the United States and one of the largest in the world.

The Authority analyzes and evaluates all reports submitted to PA-PSRS and makes recommendations for changes in healthcare practices and procedures which may improve patient safety in Pennsylvania facilities. The Authority's role is nonpunitive and is distinguished from the role of other state agencies involved in licensing healthcare facilities or individual providers.


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Comments

Since you are the Patient Safety Authority for Pennsylvania: Will your department make medical malpractice a criminal offense? Will you be compiling a database of medical practitioners (doctors, nurses, physician assistants, hospitals) who have settled medical malpractice suits, how many, and the details of the cases?
Congrats to Regina Hoffman for being on Becker's list of 50 safety experts to know! "Regina Hoffman, RN. Executive Director of Pennsylvania Patient Safety Authority (Harrisburg). Ms. Hoffman became executive director of the Pennsylvania Patient Safety Authority, an independent state agency, in 2016. She is responsible for increasing event reporting through the agency's patient safety reporting system and improving safety at 1,300 healthcare institutions across Pennsylvania. During her tenure, the agency has educated more than 34,500 professionals via conferences, webinars and on-site health facility trainings. She serves as editor-in-chief of Patient Safety, the organization's open-access, peer-reviewed journal, and as the subcommittee co-chair on learning systems for the Institute for Healthcare Improvement/Agency for Healthcare Research and Quality's National Steering Committee on Patient Safety."
“The motivations behind the nursing facilities in each sector likely play a role in the quality of care and qualifications of the staff working there — especially when one considers mission driven work versus the goals of profit driven work.” Read Article Here: