Patient Safety Authority

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

Operating as usual

Cassandra Alexander, a registered nurse with 14 years of experience in burn care, critical care transport, and intensive...
01/20/2022

Cassandra Alexander, a registered nurse with 14 years of experience in burn care, critical care transport, and intensive care, shares what it has been like on the front lines in the last two years—and the toll it has taken on her mental health. Hers is a deeply personal and painful story, yet also a traumatic experience shared by many nurses around the United States:

“I volunteered to take patients with COVID on March 14, 2020, right out of the gate, the first ones that my facility thought we had, largely because like most ICU nurses, I believed myself to be both tough and invincible. I didn’t have kids or local family to protect, and I was full of that foolish spirit that makes some of us run toward danger a little harder than others, that I think a fair amount of people who work in healthcare will recognize.

“And by April 2021 I was broken.”

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/covid-ptsd

Cassandra Alexander, a registered nurse with 14 years of experience in burn care, critical care transport, and intensive care, shares what it has been like on the front lines in the last two years—and the toll it has taken on her mental health. Hers is a deeply personal and painful story, yet also a traumatic experience shared by many nurses around the United States:

“I volunteered to take patients with COVID on March 14, 2020, right out of the gate, the first ones that my facility thought we had, largely because like most ICU nurses, I believed myself to be both tough and invincible. I didn’t have kids or local family to protect, and I was full of that foolish spirit that makes some of us run toward danger a little harder than others, that I think a fair amount of people who work in healthcare will recognize.

“And by April 2021 I was broken.”

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/covid-ptsd

Human trafficking happens all around us. Though victims are often hidden, you may encounter individuals or situations in...
01/19/2022

Human trafficking happens all around us. Though victims are often hidden, you may encounter individuals or situations in a healthcare setting. During National Slavery and Human Trafficking Prevention Month learn to spot the signs and how you can help at https://humantraffickinghotline.org/resources/what-look-healthcare-setting

Human trafficking happens all around us. Though victims are often hidden, you may encounter individuals or situations in a healthcare setting. During National Slavery and Human Trafficking Prevention Month learn to spot the signs and how you can help at https://humantraffickinghotline.org/resources/what-look-healthcare-setting

Photos from Betsy Lehman Center for Patient Safety's post
01/18/2022

Photos from Betsy Lehman Center for Patient Safety's post

Radon, which can be undetected in homes and buildings at dangerous levels, is the leading cause of lung cancer deaths am...
01/18/2022

Radon, which can be undetected in homes and buildings at dangerous levels, is the leading cause of lung cancer deaths among nonsmokers in America. During National Radon Action Month, learn about this harmful gas you can’t see, smell, or taste: https://www.atsdr.cdc.gov/csem/radon/health_effects.html.

Radon, which can be undetected in homes and buildings at dangerous levels, is the leading cause of lung cancer deaths among nonsmokers in America. During National Radon Action Month, learn about this harmful gas you can’t see, smell, or taste: https://www.atsdr.cdc.gov/csem/radon/health_effects.html.

Have you seen the new PATIENT SAFETY yet? This special issue is dedicated to pharmacy education and practice. In our cov...
01/14/2022

Have you seen the new PATIENT SAFETY yet? This special issue is dedicated to pharmacy education and practice. In our cover story, Michael Cohen, founder and president of Institute for Safe Medication Practices, shares his prescription for safety.

Cohen says, “Education is part of every healthcare professional’s responsibility. One way to do that, and an especially important area, is sharing of information about medication errors.”

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/med-error-reporting

Have you seen the new PATIENT SAFETY yet? This special issue is dedicated to pharmacy education and practice. In our cover story, Michael Cohen, founder and president of Institute for Safe Medication Practices, shares his prescription for safety.

Cohen says, “Education is part of every healthcare professional’s responsibility. One way to do that, and an especially important area, is sharing of information about medication errors.”

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/med-error-reporting

The thyroid is a small endocrine gland at the base of the neck that produces hormones aiding in the functioning of major...
01/13/2022

The thyroid is a small endocrine gland at the base of the neck that produces hormones aiding in the functioning of major organs. Hypothyroidism and hyperthyroidism can affect functioning and support to these organs. Learn more during Thyroid Health Awareness Month at https://www.cdc.gov/nceh/radiation/hanford/htdsweb/guide/thyroid.htm.

The thyroid is a small endocrine gland at the base of the neck that produces hormones aiding in the functioning of major organs. Hypothyroidism and hyperthyroidism can affect functioning and support to these organs. Learn more during Thyroid Health Awareness Month at https://www.cdc.gov/nceh/radiation/hanford/htdsweb/guide/thyroid.htm.

January 12 is National Pharmacist Day! Thank you to all the pharmacists who have been working hard to keep people health...
01/12/2022

January 12 is National Pharmacist Day! Thank you to all the pharmacists who have been working hard to keep people healthy during these unprecedented times.

In recognition of this celebration of the importance of pharmacists in the healthcare system and our lives, we are publishing PATIENT SAFETY: Pharmacy Education and Practice. Read it now at no charge: https://patientsafetyj.com/index.php/patientsaf/issue/view/23

This special issue of our journal 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 much more!

Please share with your colleagues, families, and patients and subscribe to receive our regular quarterly issues. If you would like to contribute a patient safety–related article, review, perspective, quality improvement initiative, or other manuscript, please send it to us for consideration at https://patientsafetyj.com.

January 12 is National Pharmacist Day! Thank you to all the pharmacists who have been working hard to keep people healthy during these unprecedented times.

In recognition of this celebration of the importance of pharmacists in the healthcare system and our lives, we are publishing PATIENT SAFETY: Pharmacy Education and Practice. Read it now at no charge: https://patientsafetyj.com/index.php/patientsaf/issue/view/23

This special issue of our journal 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 much more!

Please share with your colleagues, families, and patients and subscribe to receive our regular quarterly issues. If you would like to contribute a patient safety–related article, review, perspective, quality improvement initiative, or other manuscript, please send it to us for consideration at https://patientsafetyj.com.

Happy New Year from PATIENT SAFETY! As we prepare to launch our third volume, beginning with a special issue dedicated t...
01/11/2022

Happy New Year from PATIENT SAFETY! As we prepare to launch our third volume, beginning with a special issue dedicated to academic pharmacy tomorrow, we invite you to look back with us at some highlights from 2021, including the most popular articles in 2021: https://patientsafetyj.com/index.php/patientsaf/announcement/view/13

Happy New Year from PATIENT SAFETY! As we prepare to launch our third volume, beginning with a special issue dedicated to academic pharmacy tomorrow, we invite you to look back with us at some highlights from 2021, including the most popular articles in 2021: https://patientsafetyj.com/index.php/patientsaf/announcement/view/13

The Red Cross reports that they are experiencing the worst blood shortage in more than a decade, so #NationalBloodDonorM...
01/10/2022

The Red Cross reports that they are experiencing the worst blood shortage in more than a decade, so #NationalBloodDonorMonth this January is more important than ever. Low blood supply levels are forcing some hospitals to defer patients from major surgery, including organ transplants. Learn more and make an appointment at https://www.redcrossblood.org/.

The Red Cross reports that they are experiencing the worst blood shortage in more than a decade, so #NationalBloodDonorMonth this January is more important than ever. Low blood supply levels are forcing some hospitals to defer patients from major surgery, including organ transplants. Learn more and make an appointment at https://www.redcrossblood.org/.

January is National Birth Defects Prevention Month. About one in every 33 babies is born with a birth defect. Not all bi...
01/07/2022

January is National Birth Defects Prevention Month. About one in every 33 babies is born with a birth defect. Not all birth defects can be prevented, but for tips to increase your chance of a healthy pregnancy and baby visit https://cdc.gov/birthdefects.

January is National Birth Defects Prevention Month. About one in every 33 babies is born with a birth defect. Not all birth defects can be prevented, but for tips to increase your chance of a healthy pregnancy and baby visit https://cdc.gov/birthdefects.

Atrial fibrillation (AF or “AFib”) is the most common cardiac arrhythmia, manifested by the heart beating too slowly, to...
01/06/2022

Atrial fibrillation (AF or “AFib”) is the most common cardiac arrhythmia, manifested by the heart beating too slowly, too fast, or in an irregular way. People with AF can be symptomatic or asymptomatic and are at increased risk for stroke. AF also presents patient safety concerns for ambulatory surgical facilities (ASFs)—resulting in cancellations, transfers, or providing additional services to complete a procedure, which may disrupt workflow processes.

Researchers surveyed 322 Pennsylvania ASFs in March 2021 and completed a five-year study of Pennsylvania Patient Safety Reporting System (PA-PSRS) reports identifying new-onset AF, in order to examine the impact of AF on surgical facilities and identify opportunities for improvement. Among their discoveries: Cardiac arrhythmia was the most frequently identified reason for a transfer, and nearly 60% of respondents identified medical issues missed/identified during preoperative screening as one of the top four reasons for cancellations in their facility. More than 86% of the patients with new-onset AF were asymptomatic, and most were identified during the preoperative phase. For this reason, preoperative screening may identify patients at risk for AF.

Based on the results of the analysis and review of the literature, researchers identified areas of opportunity for future improvement broadly and at the facility level. Two areas for future research include screening for new-onset AF using smart devices and nurse-driven preoperative screening processes.

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/af-cancellations-analysis

Atrial fibrillation (AF or “AFib”) is the most common cardiac arrhythmia, manifested by the heart beating too slowly, too fast, or in an irregular way. People with AF can be symptomatic or asymptomatic and are at increased risk for stroke. AF also presents patient safety concerns for ambulatory surgical facilities (ASFs)—resulting in cancellations, transfers, or providing additional services to complete a procedure, which may disrupt workflow processes.

Researchers surveyed 322 Pennsylvania ASFs in March 2021 and completed a five-year study of Pennsylvania Patient Safety Reporting System (PA-PSRS) reports identifying new-onset AF, in order to examine the impact of AF on surgical facilities and identify opportunities for improvement. Among their discoveries: Cardiac arrhythmia was the most frequently identified reason for a transfer, and nearly 60% of respondents identified medical issues missed/identified during preoperative screening as one of the top four reasons for cancellations in their facility. More than 86% of the patients with new-onset AF were asymptomatic, and most were identified during the preoperative phase. For this reason, preoperative screening may identify patients at risk for AF.

Based on the results of the analysis and review of the literature, researchers identified areas of opportunity for future improvement broadly and at the facility level. Two areas for future research include screening for new-onset AF using smart devices and nurse-driven preoperative screening processes.

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/af-cancellations-analysis

Every medication has associated risks, but what happens when they’re used in combination? In particular, guidelines disc...
01/05/2022

Every medication has associated risks, but what happens when they’re used in combination? In particular, guidelines discourage using benzodiazepines in conjunction with opioid pain medications in older adults—so is it still happening, how often does it occur, and what are the consequences for geriatric patients?

Researchers examine the risks that are created when these drugs are administered together in the hospital, including an increased risk of overdose. They identified 80 reports from the Pennsylvania Patient Safety Reporting System (PA-PSRS) in which a patient may have experienced an adverse drug reaction (ADR) to the combined use of a benzodiazepine and an opioid pain medication.

They determined that changes in mental status were the most common ADRs, occurring in more than two-thirds of reports, followed by respiratory reactions (51.3%) and cardiovascular reactions (25.0%). In 70% of reports, the patient received a reversal agent, either flumazenil or naloxone, or both. The inappropriate use of benzodiazepines and opioid pain medications in combination among patients 65 years and older is a growing problem, and an increased awareness may be the first step for providers to begin addressing it.

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/benzos

Every medication has associated risks, but what happens when they’re used in combination? In particular, guidelines discourage using benzodiazepines in conjunction with opioid pain medications in older adults—so is it still happening, how often does it occur, and what are the consequences for geriatric patients?

Researchers examine the risks that are created when these drugs are administered together in the hospital, including an increased risk of overdose. They identified 80 reports from the Pennsylvania Patient Safety Reporting System (PA-PSRS) in which a patient may have experienced an adverse drug reaction (ADR) to the combined use of a benzodiazepine and an opioid pain medication.

They determined that changes in mental status were the most common ADRs, occurring in more than two-thirds of reports, followed by respiratory reactions (51.3%) and cardiovascular reactions (25.0%). In 70% of reports, the patient received a reversal agent, either flumazenil or naloxone, or both. The inappropriate use of benzodiazepines and opioid pain medications in combination among patients 65 years and older is a growing problem, and an increased awareness may be the first step for providers to begin addressing it.

Read more: https://patientsafetyj.com/index.php/patientsaf/article/view/benzos

01/04/2022

REMINDER—TODAY at 2 PM! Join PA Physician General Dr. Denise Johnson on FB Live for a discussion about COVID-19 treatment options, how and where to receive care, and if treatment is the right option if diagnosed with COVID-19.

Given the current state of affairs in healthcare facilities due to the pandemic, the webinar "Improving Diagnosis: An Ov...
01/04/2022

Given the current state of affairs in healthcare facilities due to the pandemic, the webinar "Improving Diagnosis: An Overview of the Science of Diagnostic Safety and Introduction to a Novel Improvement Project" scheduled for January 26, 2022 has been CANCELED. The webinar will be rescheduled at a later date.

Join us on Wednesday, Jan. 26 at 12 p.m. EST for a free webinar, “Improving Diagnosis: An Overview of the Science of Diagnostic Safety and Introduction to a Novel Improvement Project”: https://papsa.webex.com/papsa/onstage/g.php?MTID=ed94d3a32c923c9ca3c0490b7e1a790db

The Patient Safety Authority’s (PSA) Center of Excellence for Improving Diagnosis presents an overview of the science of diagnostic safety and an introduction to a novel improvement project. Dr. Timothy J. Mosher, physician advisor for the Center of Excellence for Improving Diagnosis, and Rebecca Jones, MBA, RN, director of the Center of Excellence for Improving Diagnosis, will describe the scope and impact of inaccurate and delayed diagnoses, demonstrate a basic understanding of diagnostic safety, including the importance of the diagnostic process, diagnostic team, and systems perspective and discuss the benefits of joining the PSA’s project to improve diagnosis and use the organizational assessment tool in your facility. *During this pilot phase, PSA will be working with acute care hospitals only.

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

Given the current state of affairs in healthcare facilities due to the pandemic, the webinar "Improving Diagnosis: An Overview of the Science of Diagnostic Safety and Introduction to a Novel Improvement Project" scheduled for January 26, 2022 has been CANCELED. The webinar will be rescheduled at a later date.

Join us on Wednesday, Jan. 26 at 12 p.m. EST for a free webinar, “Improving Diagnosis: An Overview of the Science of Diagnostic Safety and Introduction to a Novel Improvement Project”: https://papsa.webex.com/papsa/onstage/g.php?MTID=ed94d3a32c923c9ca3c0490b7e1a790db

The Patient Safety Authority’s (PSA) Center of Excellence for Improving Diagnosis presents an overview of the science of diagnostic safety and an introduction to a novel improvement project. Dr. Timothy J. Mosher, physician advisor for the Center of Excellence for Improving Diagnosis, and Rebecca Jones, MBA, RN, director of the Center of Excellence for Improving Diagnosis, will describe the scope and impact of inaccurate and delayed diagnoses, demonstrate a basic understanding of diagnostic safety, including the importance of the diagnostic process, diagnostic team, and systems perspective and discuss the benefits of joining the PSA’s project to improve diagnosis and use the organizational assessment tool in your facility. *During this pilot phase, PSA will be working with acute care hospitals only.

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

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Wednesday 9am - 5pm
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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: