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Patient Safety Authority

Patient Safety Authority The Patient Safety Authority is an independent state agency of the Commonwealth of Pennsylvania

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Let’s celebrate what goes right in hospitals and facilities every day to make patients safer. Help us make the 10th annu...
10/27/2022

Let’s celebrate what goes right in hospitals and facilities every day to make patients safer. Help us make the 10th annual I AM Patient Safety awards our best ever by nominating an individual or team for making a difference in the lives of their patients.

A panel of judges will select award winners and two runners-up in 10 categories: Ambulatory Care/Surgery Facility, Improving Diagnosis, Individual Impact (Going Above and Beyond), Long-Term Care Facility, Nationwide Warriors, Physician Offices, Safety Story (Near Miss or Close Call), Sepsis, Time-Outs, and Transparency and Safety in Healthcare.

Learn more and submit your nominations by December 20, 2022: http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS_2023_homepage.aspx

Some journals get more than 16,000 submissions every year—thousands more than any publication could ever print. That mea...
10/26/2022

Some journals get more than 16,000 submissions every year—thousands more than any publication could ever print. That means good papers won’t get published, just because there aren’t enough slots. In fact, many manuscripts may not even get a thorough read.

Our editors consider every submission carefully—so your manuscript will never be rejected because we didn’t have a chance to read it. Share your work with our 70,000+ readers worldwide! Submit your manuscript to PATIENT SAFETY today: https://patientsafetyj.com/index.php/patientsaf/about/submissions

How can you dispose of unused pills safely?Michelle Bell, BSN, RN, director of Outreach and Education with the PSA, says...
10/25/2022
Disposing of Unused Pills

How can you dispose of unused pills safely?

Michelle Bell, BSN, RN, director of Outreach and Education with the PSA, says, "Talk to your pharmacy. A lot of them have a prescription drop-off where you can take your unused medication, and they’ll dispose of it safely in a way that it’s not going to contaminate groundwater or get into the hands of a kid or a person who might use it inappropriately."

Watch and share:

"How do I dispose of unused pills safely?"Institute for Safe Medication Practices (ISMP) fellow and emergency room nurse, Michelle Bell, and medication safet...

The CDC is reporting increased  activity around the U.S. But did you know you can knock out the flu with a quick jab? Wa...
10/24/2022
Knock Out the Flu With the Patient Safety Authority

The CDC is reporting increased activity around the U.S. But did you know you can knock out the flu with a quick jab? Watch this video to learn how you can protect yourself, your family, and your community this fall and winter. https://www.youtube.com/watch?v=_7d5Z425bC0 Let’s !

This short video explains why everyone should get the flu shot every year, and why it's more important now than ever—to help protect you and your loved ones ...

It’s our favorite time of year: Nominations are now open for the I AM Patient Safety 2023 Achievement Awards! 𝘌𝘷𝘦𝘳𝘺𝘰𝘯𝘦 h...
10/24/2022

It’s our favorite time of year: Nominations are now open for the I AM Patient Safety 2023 Achievement Awards!

𝘌𝘷𝘦𝘳𝘺𝘰𝘯𝘦 has an important role in patient safety, whether you’re a registrar collecting information at admission, a nurse on the front lines, a doctor making rounds, a pharmacist filling a prescription—or a patient yourself.

𝘌𝘷𝘦𝘳𝘺𝘰𝘯𝘦 has a story, and we want to share them.

The annual IAPS contest is a way to honor those who show a commitment to patient safety, in Pennsylvania and beyond. This is your chance to tell their stories by nominating an individual or team for making a difference in the lives of their patients.

Learn more and submit your nominations by 𝗗𝗲𝗰𝗲𝗺𝗯𝗲𝗿 𝟮𝟬, 𝟮𝟬𝟮𝟮: http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS_2023_homepage.aspx

10/21/2022
Medication Safety Q&A

“Can I use a teaspoon to measure my cough syrup?”

“Is it ok to crush my pills?”

“Are generic and brand name drugs really the same?”

In this video series, Institute for Safe Medication Practices fellow and emergency room nurse, Michelle Bell, and pharmacist and medication safety officer for Children's Hospital of Philadelphia, Sharon Camperchioli, answer questions like these about medication.

Watch and share: https://www.youtube.com/playlist?list=PLwJn-tgLXAJINLAygdyb5QocbAcDIiNUu

Institute for Safe Medication Practices (ISMP) fellow and emergency room nurse, Michelle Bell, and medication safety officer for Children’s Hospital of Phila...

Please join us on Tuesday, Oct. 27, at 1 p.m. ET for "Avoiding the Clinical Equipment Land Mines – WellSpan Health’s Mis...
10/21/2022

Please join us on Tuesday, Oct. 27, at 1 p.m. ET for "Avoiding the Clinical Equipment Land Mines – WellSpan Health’s Mission For Zero Patient Harm."

Clinical equipment—even the most common types—can expose patients to risk and cause an adverse event. This FREE webinar will share how WellSpan’s Clinical Equipment Review Team (CERT), recall management program, and Medical Equipment Reprocessing-Quality Assurance department (MERQA) support their mission for Zero Patient Harm.

1.0 continuing education hours will be awarded for completion of this webinar. Continuing education credits apply to Pennsylvania registered nurses only.

Register now at https://papsa.webex.com/papsa/onstage/g.php?MTID=eb27a2bcb9463091553ffa46895a70ac4

To recognize the importance of pharmacists in the healthcare system and our lives, we published PATIENT SAFETY: Pharmacy...
10/19/2022

To recognize the importance of pharmacists in the healthcare system and our lives, we published PATIENT SAFETY: Pharmacy Education and Practice earlier this year: https://patientsafetyj.com/index.php/patientsaf/issue/view/23

It features timely manuscripts from pharmacy students, practitioners, educators, and experts, including data on antibiotic stewardship in a community hospital ED, how a hospital and pharmacy school collaborated to foster a culture of safety, ways to keep children and babies safe from medication errors in the hospital, the importance of sharing information and stories in improving med safety, how to build good habits for practice—and more!

Please share with your colleagues, families, and patients. If you have a patient safety–related manuscript, please send it to us for a future issue at https://patientsafetyj.com.

Event Recap: 2022 PA Nurse Residency Collaborative Summit
10/19/2022
Event Recap: 2022 PA Nurse Residency Collaborative Summit

Event Recap: 2022 PA Nurse Residency Collaborative Summit

The PA Nurse Residency Collaborative (PA-NRC) hosted its fourth leadership summit titled, The Nurse’s Role in Patient Safety: Reflecting on Our Oath in collaboration with the annual Pennsylvania Organization of Nurse Leaders' (PONL) Nursing Leadership Conference. Presentations included: [list ...

National Pharmacy Week (happening now!) is an annual observance that acknowledges the invaluable contributions that phar...
10/18/2022

National Pharmacy Week (happening now!) is an annual observance that acknowledges the invaluable contributions that pharmacists and pharmacy technicians make to patient care in hospitals, ambulatory care clinics, and other healthcare settings. Throughout the week, we will share articles, videos, and resources that will help ensure safe and effective medication use.

Learn more about : ashp.org/pharmacyweek

International Infection Prevention Week (), October 16-22, celebrates the importance of infection prevention and the rol...
10/17/2022

International Infection Prevention Week (), October 16-22, celebrates the importance of infection prevention and the role of IPs in protecting public health. Raise your voice and spread thanks to IPs around the world! www.apic.org/InfectionPreventionandYou

10/14/2022

Do you have a manuscript related to patient safety? Send it to the Patient Safety Authority’s award-winning journal today and have it read by 70,000+ people worldwide: patientsafetyj.com

Accepted articles are published ~14 weeks from submission. There are NO FEES for authors or readers.

Malpractice claims often go one of two ways: they reach trial and become public knowledge or they’re settled out of cour...
10/13/2022

Malpractice claims often go one of two ways: they reach trial and become public knowledge or they’re settled out of court and are locked up in a nondisclosure clause, which prevents the public from not only learning about it, but also learning from it. Doctors Charles Pilcher and Mark Graber point out the missed opportunity of sharing these buried stories—anonymously—to improve patient safety and prevent these mistakes from happening again:

“Capturing the stories of patients who have been harmed by medical error is crucial. Stories are more effective teaching tools than academic papers and meta-analyses. Every great communicator understands that there is no better way to capture a reader’s attention than by starting off with a story.”

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/malpractice-settlements

We know healthcare in Canada differs from healthcare in the United States, but how does patient safety compare across th...
10/12/2022

We know healthcare in Canada differs from healthcare in the United States, but how does patient safety compare across the border? Ioana Popescu, director of Safety Strategies & Programs for Healthcare Excellence Canada, provides a comprehensive look at incident reporting and patient safety agencies and initiatives in her country.

She points out that no matter where you are, keeping patients safe includes learning from incidents so you can prevent them from recurring, and that requires data reporting and a strong culture of safety. While national incident reporting in Canada is limited to events involving medications, adverse drug reactions, and device failures, organizations such as the Canadian Institute for Health Information (CIHI) have helped bridge the gap. And patient groups, like Patients for Safety Canada, are ensuring that patients and their families are included in the conversation too.

To continue doing well, and do better, Popescu writes, “Patient safety is considered a global public health issue. Continued collaboration and learning and sharing with patients, families, and healthcare workers at all system levels—from local to global—have been and will continue to be essential.”

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/patient-safety-in-canada

“Can I use a teaspoon to measure my cough syrup?” “Is it ok to crush my pills?” “Are generic and brand name drugs really...
10/11/2022

“Can I use a teaspoon to measure my cough syrup?” “Is it ok to crush my pills?” “Are generic and brand name drugs really the same?”

People often have questions like these about their medications, but they’re too embarrassed to ask—or they don’t know whom to ask. In recognition of World Patient Safety Day 2022 on September 17, with the theme “Medication Without Harm,” 𝘗𝘢𝘵𝘪𝘦𝘯𝘵 𝘚𝘢𝘧𝘦𝘵𝘺 collected questions about medication safety and consulted two experts to answer them: Michelle Bell, BSN, RN, director of Outreach & Education at the PSA and an Institute for Safe Medication Practices fellow, and Sharon Camperchioli, Pharm D, the medication safety officer at Children's Hospital of Philadelphia.

In response to the question “How can I dispose of unused pills safely?” Bell responded, “Unused medication is a challenge for a lot of people. You might have a prescription that gets changed or you might need a different dose. Talk to your pharmacy. A lot of them have a prescription drop-off where you can take your unused medication, and they’ll dispose of it safely in a way that it’s not going to contaminate groundwater or get into the hands of a kid or a person who might use it inappropriately and then get sick or harmed from it.”

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/med-safety-q-and-a

Share your patient safety–related research, quality improvement studies, perspectives, and more with healthcare leaders,...
10/07/2022

Share your patient safety–related research, quality improvement studies, perspectives, and more with healthcare leaders, caregivers, providers, and patients around the world. Send your manuscript to PATIENT SAFETY now: https://patientsafetyj.com/index.php/patientsaf/about/submissions.

With our quick turnaround times, articles we receive today could be published as soon as March 2023! Don't have anything ready for submission yet? Please tell your colleagues about PATIENT SAFETY. Together we save lives.

⚠️𝗦𝗮𝗳𝗲𝘁𝘆 𝗔𝗹𝗲𝗿𝘁: 𝗔𝗶𝗿 𝗘𝗺𝗯𝗼𝗹𝗶𝘀𝗺 𝗗𝘂𝗿𝗶𝗻𝗴 𝗖𝗮𝗿𝗱𝗶𝗮𝗰 𝗔𝗯𝗹𝗮𝘁𝗶𝗼𝗻During a cardiac ablation procedure, the catheter irrigation fluid b...
10/07/2022

⚠️𝗦𝗮𝗳𝗲𝘁𝘆 𝗔𝗹𝗲𝗿𝘁: 𝗔𝗶𝗿 𝗘𝗺𝗯𝗼𝗹𝗶𝘀𝗺 𝗗𝘂𝗿𝗶𝗻𝗴 𝗖𝗮𝗿𝗱𝗶𝗮𝗰 𝗔𝗯𝗹𝗮𝘁𝗶𝗼𝗻
During a cardiac ablation procedure, the catheter irrigation fluid bag emptied and was replaced by staff. While priming the tubing, air was noted in the tube, and the catheter was immediately removed from the patient. The patient experienced a decrease of heart rate and blood pressure requiring a code response.

Background:
Radiofrequency cardiac ablation requires the use of heparinized irrigation fluid to cool and anticoagulate the ablation site. If the procedure requires more fluid than originally hung, it requires the bag to be replaced. This introduces an opportunity for air to enter the irrigation tubing. Air emboli can then be infused into the patient causing cardiac arrhythmia, myocardial infarction, respiratory symptoms and/or neurologic symptoms, and, potentially, total cardiovascular collapse.

𝗦𝗼𝗹𝘂𝘁𝗶𝗼𝗻𝘀:
• During cardiac ablation procedures, air should be removed from any bags and the pump (or any other pressurized delivery device) tubing primed before being connected to a patient.
• Do not bypass alarms that detect air in the pump or tubing systems.
• Do not prime the irrigation line without first disconnecting the tubing set from the patient, even if a stopcock is in use.
• Review the manufacturer’s instructions for how to change fluid bags to ensure safe operations.
• Be aware of potential access points for air to enter the system and mitigate the risk.

Change is hard, but making lasting changes to improve patient safety is even more difficult when healthcare workers are ...
10/06/2022

Change is hard, but making lasting changes to improve patient safety is even more difficult when healthcare workers are too afraid to speak up about problems. Kristin Neiswender and her team at Children's Hospital of Philadelphia found a formula for success—which resulted in a 13% increase in staff rating scores for safety culture after two years—and they share how they implemented their novel, multifaceted just culture training program at the hospital, as well as the eight biggest lessons they learned along the way.

Lesson 1: Be thoughtful about who performs error follow-up. The simple step of removing direct supervisors from the incident review process made staff more open to discuss what went wrong. Lesson 2: Preparation matters. Those involved with reviewing the incident need to take their role and responsibility seriously and familiarize themselves with all the details of what happened and their organization’s related policies. Other takeaways underscore the importance of buy-in from leadership; sharing communication skills to help navigate challenging conversations and focus on the event, not the individual; and ongoing support and guidance to teams.

Five years after piloting this training, program leaders believe this model could be used across the organization for any type of error, and at any organization willing to commit time and resources to improving staff engagement and safety culture.

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/error-review-just-culture

THE LOWDOWN is our quarterly resource for promoting a safe, positive environment for staff and residents of long-term ca...
10/05/2022

THE LOWDOWN is our quarterly resource for promoting a safe, positive environment for staff and residents of long-term care facilities. The fall edition includes safety tips on preventing infections, including aspiration pneumonia, as well as guidance on drug diversion by healthcare providers. Read and share:http://patientsafety.pa.gov/Documents/The%20Lowdown_Fall%202022.pdf

10/04/2022

❓ Do you have a manuscript related to patient safety?

📑 Send it to the Patient Safety Authority’s award-winning journal today and have it read by 70,000+ people worldwide: patientsafetyj.com

Each year more than 7 million hospitalized patients in the United States suffer from delirium, a state of confusion that...
10/04/2022

Each year more than 7 million hospitalized patients in the United States suffer from delirium, a state of confusion that comes on suddenly—yet it remains an underrecognized diagnosis from care teams. Symptoms can range from drowsiness (hypoactive delirium) to restlessness or agitation (hyperactive delirium), or a combination of these extremes. If delirium isn’t identified, an episode can last for hours or days, and it typically extends a hospital stay by 10 days; however, if the underlying cause is treated, it can be resolved more quickly.

Anyone with a serious illness can develop delirium, even younger people, especially if they are in an intensive care unit or on mechanical ventilation—or undergoing treatments for cancer. To help increase early identification of delirium and reduce the safety risks, costs, and length of stay for patients, Cassandra Vonnes, DNP, from the Moffitt Cancer Center and Cindy Tofthagen, PhD, from the Mayo Clinic Florida implemented a quality improvement project around routine delirium screening by the nursing team. Their study provides an in-depth look at how facilities can come together to identify a problem and embrace lasting change that has a positive impact on staff and patients.

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/delirium-screening-oncology

10/03/2022

📌 Stuck in the slush pile?

🖋 Consider sending your next manuscript to the Patient Safety Authority’s peer-reviewed journal, PATIENT SAFETY: www.patientsafetyj.com

👀 Editors read and respond to most submissions in just 2️⃣ weeks.

💻 Upon acceptance articles are published in print & online in

An estimated 1 in every 182 Americans will be diagnosed with cancer this year. Providing them safe care has inherent cha...
10/03/2022

An estimated 1 in every 182 Americans will be diagnosed with cancer this year. Providing them safe care has inherent challenges, such as reaching an accurate diagnosis as quickly as possible, differentiating between disease progression and treatment side effects, and addressing broader systemic risks. Patient Safety managing editor Caitlyn Allen, sat down with Dr. Joseph O. Jacobson, oncologist and former chief quality officer of the Dana-Farber Cancer Institute, to discuss the evolution of oncology care and what the future may hold.

Jacobson says, “Cancer care today is much more of a team effort than it ever has been, and the patient must be a critical member of that team, actively involved in all care decisions. Treatments today are often highly complex and may be dispersed across a complex network of providers with more and more emphasis on outpatient care.” While this has made some things easier, such as making it more convenient for patients to receive chemotherapy and even bone marrow transplantation, it also makes it more challenging for the clinical team to coordinate complex care and ensure patient safety. He adds, “At the same time, it shifts more and more responsibility to the patient and her caregivers.”

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/safe-cancer-care

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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.”

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