Patient Safety Authority

Patient Safety Authority The Patient Safety Authority is an independent state agency of the Commonwealth of Pennsylvania
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Popular now in PATIENT SAFETY: In general, healthy adults shouldn’t have more than 400 mg of caffeine a day, but energy ...
06/18/2024

Popular now in PATIENT SAFETY: In general, healthy adults shouldn’t have more than 400 mg of caffeine a day, but energy drinks contain anywhere from 100 to 300 mg. What’s the risk? Taking in a lot of caffeine in a short period could result in acute caffeine intoxication and symptoms like anxiety, restlessness, sleeplessness, elevated heart rate, tremors, and nausea. Severe overdoses can cause potentially fatal heart problems or seizures. Be aware that highly caffeinated beverages may not prominently advertise their caffeine content, so healthcare providers should consider informing their patients about safe energy drink use.

Read and share this important study:

By Alexandra Lichvar, Amrit Pabla & 2 more. Energy drinks have been one of the fastest growing products in the beverage and supplement industries. Their ubiquity in society has grown exponentially over the last two decades...

Do you have a manuscript related to patient safety? Send it to our award-winning journal and it could be read by 75K+ pe...
06/15/2024

Do you have a manuscript related to patient safety? Send it to our award-winning journal and it could be read by 75K+ people worldwide. Accepted articles are published on a rolling basis as soon as production has been completed. There are NO FEES for authors or readers.

Check out our current issue and send us your best work!

Articles published on a rolling basis from January 1, 2024, to December 31, 2024.

Just published: The Outpatient Department (OPD) of Al Hada Armed Forces Hospital - Taif Region (AHAFH) plays a critical ...
06/13/2024

Just published: The Outpatient Department (OPD) of Al Hada Armed Forces Hospital - Taif Region (AHAFH) plays a critical role in providing specialized medical services to a diverse population in Taif region, Saudi Arabia. The hospital faces the challenge of ensuring timely access to a comprehensive array of 40 specialized services and subspecialties, supported by 120 rooms in the OPD. This article outlines a significant understanding of the patient flow process and queuing mechanism in the context of the OPD and the dynamics of supply and demand.

Read it now in PATIENT SAFETY:

By Reynan S. Bautista, Muhammad H. Abid & 5 more. The Outpatient Department (OPD) of Al Hada Armed Forces Hospital - Taif Region (AHAFH) plays a critical role in providing specialized medical services to a diverse population in Taif region...

Just published: Alteplase and tenecteplase are thrombolytic agents used to treat patients with acute ischemic stroke (AI...
06/11/2024

Just published: Alteplase and tenecteplase are thrombolytic agents used to treat patients with acute ischemic stroke (AIS). Despite the convenient bolus dosing of tenecteplase, its off-label use for AIS creates new patient safety challenges that are understudied.

Safety events involving alteplase and tenecteplase in the treatment of AIS are diverse. This article presents a list of potential strategies to prevent and mitigate errors involving these high-alert medications and encourage providers to adopt those that are meaningful to their workflow and practice setting.

Read more in PATIENT SAFETY:

By Myungsun Ro, Matthew A. Taylor & 1 more. Alteplase and tenecteplase are thrombolytic agents used to treat patients with acute ischemic stroke (AIS). Despite the convenient bolus dosing of tenecteplase, its off-label use for AIS creates new patient...

Just published: In the realm of healthcare quality, outpatient parenteral antimicrobial therapy (OPAT) has emerged as th...
06/07/2024

Just published: In the realm of healthcare quality, outpatient parenteral antimicrobial therapy (OPAT) has emerged as the gold standard for managing patients who have transitioned from inpatient care but still require extended intravenous antimicrobial treatment. The adoption of OPAT at Al Hada Armed Forces Hospital in Taif, Saudi Arabia, not only bolsters patient satisfaction but also serves as a catalyst for reduced hospitalization durations, lower rates of emergency department readmissions, and an overall reduction in healthcare expenditures. The main objective of this study was to evaluate the effectiveness of OPAT in a tertiary center facility in Saudi Arabia.

Read this article now in PATIENT SAFETY:

By Jean B. De Asis, Abdulrahman Al Ghamdi & 3 more. In the realm of healthcare quality, outpatient parenteral antimicrobial therapy (OPAT) has emerged as the gold standard for managing patients who have transitioned from inpatient care but still require...

PATIENT SAFETY is currently open to research articles, quality improvement studies, focused reviews, patient perspective...
06/06/2024

PATIENT SAFETY is currently open to research articles, quality improvement studies, focused reviews, patient perspectives, commentaries, data analyses, and other manuscripts that can help advance safety in healthcare.

Learn more and submit your work at https://patientsafetyj.com/about. We look forward to reading it!

How much caffeine have you had today? Are you sure? If you start your mornings with a cup of coffee (about 95 milligrams...
06/04/2024

How much caffeine have you had today? Are you sure? If you start your mornings with a cup of coffee (about 95 milligrams of caffeine), you probably don’t have much to worry about, but if you also consume energy drinks or supplements, you should pay attention to their ingredients.

In general, healthy adults shouldn’t have more than 400 mg of caffeine a day, but energy drinks contain anywhere from 100 to 300 mg. What’s the risk? Taking in a lot of caffeine in a short period could result in acute caffeine intoxication and symptoms like anxiety, restlessness, sleeplessness, elevated heart rate, tremors, and nausea. Severe overdoses can cause potentially fatal heart problems or seizures. Also be careful of highly caffeinated beverages, which may not prominently advertise their caffeine content, and be aware of potential interactions with medications, recreational drugs, and existing health conditions. Healthcare providers can take an active role in informing their patients about safe energy drink use.

Learn more:

By Alexandra Lichvar, Amrit Pabla & 2 more. Energy drinks have been one of the fastest growing products in the beverage and supplement industries. Their ubiquity in society has grown exponentially over the last two decades...

Enhanced Barrier Precautions (EBP) are an evidence-based best practice designed to reduce the spread of multidrug-resist...
05/31/2024

Enhanced Barrier Precautions (EBP) are an evidence-based best practice designed to reduce the spread of multidrug-resistant organisms (MDROs) by expanding the use of gloves and gowns during high-contact resident care activities, especially for those at increased risk of acquiring or spreading an MDRO. EBP were released by the Centers for Disease Control and Prevention (CDC) in 2019 and are now regulated.

This webinar discusses the targeted, high-risk pathogens which require EBP, the components of EBP, and when to institute them: https://youtu.be/kTSVczzoad4

On March 20, 2024, the Centers for Medicare & Medicaid Services (CMS) issued new guidance for state survey agencies and long-term care (LTC) facilities on the use of EBP to prevent the spread of MDROs (QSO-24-08-NH Enhanced Barrier Precautions in Nursing Homes).

Recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities, regardless of their MDRO status. The new guidance related to EBP is being incorporated into F880 Infection Prevention and Control.

Please add EBP into your practice if your facility is not currently using them. Patient Safety Authority infection prevention advisors are available to answer any questions about EBP that you may have.

In this month's issue of Patient Safety Beat, Betsy Lehman Center for Patient Safety publishes articles on the challenge...
05/29/2024

In this month's issue of Patient Safety Beat, Betsy Lehman Center for Patient Safety publishes articles on the challenges nurses and physicians face in transitioning from education to practice, supporting new nurses with residency programs, and a proposed new patient safety attestation measure to help Centers for Medicare & Medicaid Services assess safety cultures and structures in hospitals.

In the May issue of Patient Safety Beat, health care leaders in the state discuss ECRI's top patient safety concern for 2024: Challenges transitioning newly trained clinicians from education into practice. Read more about how provider organizations are adapting their approaches and strategies: https://buff.ly/4av9t9T

OPEN CALL FOR SUBMISSIONS of patient safety–related manuscripts: We are looking for research articles, quality improveme...
05/24/2024

OPEN CALL FOR SUBMISSIONS of patient safety–related manuscripts: We are looking for research articles, quality improvement studies, focused reviews, patient perspectives, commentaries, data analyses, and more—if your work can help advance safety in healthcare, we want to see it.

Visit https://patientsafetyj.com/about to read articles, review our guidelines, and submit your original manuscript today. Please share with your networks, colleagues, and students.

Long-term care (LTC) facilities must protect residents, staff, and visitors during threats and hazards—including natural...
05/23/2024

Long-term care (LTC) facilities must protect residents, staff, and visitors during threats and hazards—including natural disasters. Are you ready to handle anything?

Pennsylvania is vulnerable to multiple threats and hazards, including severe weather, floods, fires, tornadoes, active shooters, and infectious disease outbreaks. While these are problems in themselves, they also may disrupt vital supplies and services such as power, telephone, potable water, food, medical supplies, and gasoline. Preparing for disasters is critical for ensuring the safety of everyone at LTC facilities.

Download, read, and share our new preparedness toolkit, which provides guidance, policies, and procedures to help you plan an effective response to hazardous situations and ensure safety at your facility: https://patientsafety.pa.gov/pst/Pages/Emergency%20Preparedness/hm.aspx?t=tools

There are two things to know about glacial acetic acid. First, what it is: You probably already have acetic acid in your...
05/22/2024

There are two things to know about glacial acetic acid. First, what it is: You probably already have acetic acid in your kitchen, where it’s more commonly known as vinegar (about 96% water and 4% acetic acid). When diluted to even lower concentrations, acetic acid also has medical uses; for example, diluted to a 0.25% concentration for irrigation during medical procedures. Glacial acetic acid, on the other hand, is pure acetic acid with essentially no water content. At a concentration of 99.5%—100%, it is highly corrosive and has been associated with serious patient harm, including severe tissue damage and third-degree burns. Glacial acetic acid has no medical purpose, so the most important thing you need to know about it is stop using it. Staff should follow best practice recommendations on purchasing and using acetic acid safely.

Read more and share:

By Myungsun Ro. Multiple events involving patient harm from the use of undiluted glacial acetic acid have been reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS). Glacial acetic acid is anhydrous pure...

Trauma-informed care recognizes that using devices, materials, or equipment (such as bed straps) to restrict or limit a ...
05/20/2024

Trauma-informed care recognizes that using devices, materials, or equipment (such as bed straps) to restrict or limit a patient’s movement may harm them both physically and psychologically, as well as make a situation worse or damage the patient-caregiver relationship. Believing that mechanical restraints should only be carefully considered after all other less-restrictive interventions and de-escalation efforts have been exhausted, Belmont Behavioral Health System implemented a quality improvement project to reduce the use of four-point restraints. Dubbed “Operation Last Resort,” this initiative shifted culture to view mechanical restraint not as treatment but as a failure of treatment, and provided staff with de-escalation training as an alternative, and successfully sustained zero use of mechanical restraints for at least a year.

Read and share:

By Dawn Bausman, Shawna Gigliotti & 1 more. The use of restrictive interventions, such as mechanical restraints, has been a common practice in behavioral health settings since the field’s early infancy. The use of restraints has a harmful...

How much caffeine have you had today? Are you sure? If you start your mornings with a cup of coffee (about 95 milligrams...
05/17/2024

How much caffeine have you had today? Are you sure? If you start your mornings with a cup of coffee (about 95 milligrams of caffeine), you probably don’t have much to worry about, but if you also consume energy drinks or supplements, you should pay attention to their ingredients.

In general, healthy adults shouldn’t have more than 400 mg of caffeine a day, but energy drinks contain anywhere from 100 to 300 mg. What’s the risk? Taking in a lot of caffeine in a short period could result in acute caffeine intoxication and symptoms like anxiety, restlessness, sleeplessness, elevated heart rate, tremors, and nausea. Severe overdoses can cause potentially fatal heart problems or seizures. Also be careful of highly caffeinated beverages, which may not prominently advertise their caffeine content, and be aware of potential interactions with medications, recreational drugs, and existing health conditions. Healthcare providers can take an active role in informing their patients about safe energy drink use.

Read and share:

By Alexandra Lichvar, Amrit Pabla & 2 more. Energy drinks have been one of the fastest growing products in the beverage and supplement industries. Their ubiquity in society has grown exponentially over the last two decades...

05/14/2024

Have you ever used a knife to cut a pill? What harm can it do, right? It turns out you should *always* use a pill cutter and wear gloves to cut pills to make sure the patient is getting the right dose and no one else is exposed to the medication.

This  , here’s just one example of how nurses go above and beyond to keep patients safe.After a hospital received severa...
05/10/2024

This , here’s just one example of how nurses go above and beyond to keep patients safe.

After a hospital received several event reports of wrong and expired intravenous (IV) fluids caught before reaching patients, the medication safety officer investigated how these products were supplied. This institution purchases all their plain IV fluids from one manufacturer, so the products appear very similar. The fluids were stocked in clean utilities rooms throughout the patient care units in blue storage bins with white labels describing the contents by product number. Although nursing uses barcode medication administration (BCMA) technology prior to administering drugs to patients, the hospital lacked any technology to help ensure storeroom staff placed the correct product in its bin.

This information was shared with the patient safety director and the reporting nurse, who appreciated a significant look-alike risk. Their group developed a plan to provide visual differentiation of each product, evaluate fluids and quantities stocked, and reorganize the fluids according to prevalence of use.

Since they could not change the appearance of the products in stock, the group worked to color code storage according to the type of solution. Their original plan was to purchase different color bins; however, the cost was prohibitive, so instead they purchased different color labels which clearly state the type of fluid and bag size. These labels were used on storage bins throughout the patient care units and storeroom. A small supply of different color bins was purchased for the storeroom staff to use when transporting the fluids to the floor to prevent intermingling.

To better understand the supply maintained on each unit, the medication safety officer met with nurse managers to review items stocked compared to actual use. Each unit reevaluated its supply to ensure more appropriate quantities of regularly used items were available. This reduced the number of different fluid products from 22 to 15. Of the 15 products kept, nine had periodic automatic replacement (PAR) levels adjusted to match average use. This helped reduce risk of products expiring and waste.

When the new labels were implemented, the group reorganized the fluids to store them more ergonomically for staff. Prior to this, irrigation solutions and combination fluid products were stored at eye level and high use items, like sodium chloride 0.9% or lactated Ringer’s 1-liter bags, were stored on the bottom shelf. Staff routinely needed to bend down to take or restock these products. Solutions also were organized by product number, which separated different bag sizes of the same fluids. In the new system, the same fluids are grouped together and more routinely used items are placed higher on shelves.

Read more stories of nursing changemakers: http://patientsafety.pa.gov/EventReporting/Pages/evrpt_category.aspx?ctg=nursing

We know about the impact of burnout on clinicians, but how does it affect patient safety? Burnout contributes to inatten...
05/09/2024

We know about the impact of burnout on clinicians, but how does it affect patient safety? Burnout contributes to inattention which can increase the risk of medical errors, as well as employee turnover, reducing the number of those who can provide safe care. In response to this growing concern, some healthcare facilities have developed programs to reduce burnout and support their staff—which may still fall short of what they truly need. This study looks at what nurses have been saying about their concerns and well-being on social media, which may inform the programs designed to help healthcare workers manage burnout and stress. Read more: https://patientsafetyj.com/article/88305-are-they-aligned-an-analysis-of-social-media-based-nurse-well-being-concerns-and-well-being-programs

By Arianna P. Milicia, Jessica L. Handley & 7 more. Nurse burnout and distress pose patient safety risks due to impaired nurse attention, increased likelihood of medical error, and increased nurse turnover leading to a reduction in the number of...

Are we adequately preparing nurses to enter the workforce? Toothaker et al. interviewed 11 nurses in their first six mon...
05/08/2024

Are we adequately preparing nurses to enter the workforce? Toothaker et al. interviewed 11 nurses in their first six months following graduation about their personal experiences and struggles in transitioning from school to practice. They shared some common themes and challenges, including a lack of practical knowledge, feelings of impostor syndrome, concerns about the safety of workers and patients, and internalized fear. The stories and data the researchers collected suggest solutions may lie in enhancing the academic curriculum, better mentoring, and nurse residency programs. Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/nurse-transition

By Rebecca Toothaker, Marijo A. Rommelfaenger & 2 more. Background: The nurse’s transition into practice is challenging. The need to facilitate a safe transition into practice and retain nurses is crucial in today’s healthcare. Objective and Design: The qualitative...

A pressure injury (PI), defined as “localized damage to the skin and underlying soft tissue, usually over a bony promine...
05/07/2024

A pressure injury (PI), defined as “localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device,” is largely preventable. To discover and implement more PI interventions, it’s important for clinical staff to identify P*s accurately when they occur and document their progression. In response to a recognized gap in bedside nurses’ knowledge surrounding P*s, a recent study introduced PI education programs in a facility’s nursing unit, which demonstrated improvement in nurses’ knowledge of PI assessment, staging, and documentation, and points the way to finding other ways to improve training on P*s. Read more: https://patientsafetyj.com/article/73614

By Kathleen Sankovich, Rosemary Hoffmann & 2 more. Background: Pressure Injuries (P*s) are largely preventable. Accurate documentation of PI stage or progression is a key quality measure. Local Problem: Nurses frequently fail to accurately assess and document their...

From May 6–12, National Nurses Week celebrates the invaluable contributions of America’s more than 5 million registered ...
05/06/2024

From May 6–12, National Nurses Week celebrates the invaluable contributions of America’s more than 5 million registered nurses. The American Nurses Association has selected the theme “Nurses Make the Difference” to honor the vital role they play in keeping everyone healthy. Show your appreciation and support by posting a photo of your favorite nurse(s) on social media with the hashtag !

05/03/2024

Do you have a manuscript related to patient safety? Send it to our award-winning journal and it could be read by 75K+ people worldwide. Accepted articles now are published on a rolling basis as soon as production has been completed. There are NO FEES for authors or readers. https://patientsafetyj.com/

📌 In conjunction with the Patient Safety Authority’s 2023 annual report, we published two articles in PATIENT SAFETY ana...
05/02/2024

📌 In conjunction with the Patient Safety Authority’s 2023 annual report, we published two articles in PATIENT SAFETY analyzing 2023 data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), the nation’s largest event reporting database.

📌 In “Patient Safety Trends in 2023,” PSA data analysts take a close look at the 287,997 serious events and incidents reported by acute care facilities last year, while “Long-Term Care Healthcare-Associated Infections in 2023” examines 23,970 HAI reports from long-term care facilities last year.

📌 They supplement the data overview in the annual report with a comprehensive review and analysis of events reported in 2023, as well as insights into patient safety in Pennsylvania and how we may continue to improve it together.

📌 Read and share:
https://patientsafetyj.com/article/116529-patient-safety-trends-in-2023-an-analysis-of-287-997-serious-events-and-incidents-from-the-nation-s-largest-event-reporting-database

By Shawn Kepner, Rebecca Jones. With more than 4.7 million events, Pennsylvania continues to lead the nation in patient safety reporting.

We are pleased to share our 2023 annual report, highlighting PSA’s commitment to safer care for Pennsylvanians. Last yea...
05/01/2024

We are pleased to share our 2023 annual report, highlighting PSA’s commitment to safer care for Pennsylvanians. Last year’s accomplishments include

🔷 Implemented new tools and processes to enhance the monitoring, review, and analysis of Pennsylvania Patient Safety Reporting System (PA-PSRS) data, including state-of-the-art modeling techniques using artificial intelligence along with statistical testing.

🔷 Worked with facilities to improve event reporting and investigation, including a Keystone webinar series focused on identifying causes and contributing factors of safety events and actions that can minimize the risk of future harm.

🔷 Created a searchable microsite of stories of events that inspired people to make changes that improved patient care and safety at their facility and beyond.

🔷 Published a free handbook to foster better communication between patients and healthcare providers, and help patients take a more active and effective role in their own care.

Also check out our full analyses of acute care and long-term care events reported last year in PA-PSRS, the largest repository of patient safety data in the United States and one of the largest in the world, with over 5 million event reports.

Read and share the PSA’s 2023 Annual Report athttps://patientsafety.pa.gov/PatientSafetyAuthority/Documents/2023%20Annual%20Report_FINAL.pdf

World Immunization Week is celebrated in the last week of April each year, an opportunity to highlight what everyone can...
04/25/2024

World Immunization Week is celebrated in the last week of April each year, an opportunity to highlight what everyone can do to help protect people of all ages against vaccine-preventable diseases. Watch and share this webinar with JoAnn Adkins, BSN, RN, PSA infection prevention advisor, about the importance of vaccinations for everyone, the role vaccination plays in developing immunity, how community immunity helps prevent the spread of disease, and the three vaccinations important to healthcare workers:

JoAnn Adkins, BSN, RN, senior infection preventionist at the Patient Safety Authority, discusses the importance of vaccinations for everyone, describes the r...

Just published in PATIENT SAFETY: Check out our full analysis of long-term care (LTC) events reported last year in PA-PS...
04/24/2024

Just published in PATIENT SAFETY: Check out our full analysis of long-term care (LTC) events reported last year in PA-PSRS, the largest repository of patient safety data in the United States and one of the largest in the world, including 420,000 LTC healthcare-associated infections since 2009. https://doi.org/10.33940/001c.116555

Just published in PATIENT SAFETY: Check out our full analysis of acute care events reported last year in PA-PSRS, the la...
04/23/2024

Just published in PATIENT SAFETY: Check out our full analysis of acute care events reported last year in PA-PSRS, the largest repository of patient safety data in the United States and one of the largest in the world, with over 4.7 million event reports. https://doi.org/10.33940/001c.116529

Did you know that hand hygiene is the most important measure you can use to prevent the spread of infection? Many studie...
04/22/2024

Did you know that hand hygiene is the most important measure you can use to prevent the spread of infection? Many studies show that improved hand hygiene reduces infection rates. The spring edition of THE LOWDOWN focuses on how “basic” best practices like handwashing, good personal hygiene, and environmental cleaning can keep germs from spreading among long-term care residents, visitors, and staff. Please read and share with your fellow colleagues and residents:https://patientsafety.pa.gov/pst/Documents/Infection%20Prevention/The%20Lowdown_Spring%202024.pdf

While it is rare, intentional harm of a patient by a healthcare provider can happen. Does your facility have a process t...
04/19/2024

While it is rare, intentional harm of a patient by a healthcare provider can happen. Does your facility have a process to identify patterns of possible murder by healthcare providers? How would you respond if you were faced with a situation like this?

In this recent webinar, Zane Robinson Wolf, PhD, RN, dean emerita and professor at the School of Nursing and Health Sciences, La Salle University, discusses how to recognize murder by healthcare professionals as a significant patient safety threat, analyzes selected cases of healthcare providers alleged or convicted of murder, reviews the motives of alleged or convicted healthcare providers charged with serial murder, and evaluates patterns of possible murder by healthcare providers.

Watch and share:

While it is rare, intentional harm of a patient by a healthcare provider can happen. Does your facility have a process to identify patterns of possible murde...

04/16/2024

Advance directives are important because they help make sure someone’s wishes are carried out even when they may not be able to speak for themself. There are a few different kinds of advance directives: living will, durable power of attorney, physician orders for life-sustaining treatment, and do not resuscitate order.

Other advance directives include ventilation (mechanical breathing), tube feeding, palliative (comfort) care, and organ donation. You have the right to decide which, if any, of these things you want.

Download, read, and share 𝘛𝘩𝘦 𝘗𝘢𝘵𝘪𝘦𝘯𝘵’𝘴 𝘊𝘰𝘮𝘱𝘢𝘯𝘪𝘰𝘯, a handbook to help patients better understand their healthcare and help providers better understand their patients: https://patientsafety.pa.gov/handbook

PATIENT SAFETY is currently open to research articles, quality improvement studies, focused reviews, patient perspective...
04/12/2024

PATIENT SAFETY is currently open to research articles, quality improvement studies, focused reviews, patient perspectives, commentaries, data analyses, and other manuscripts that can help advance safety in healthcare.

Learn more and submit your work at https://patientsafetyj.com. We look forward to reading it!

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