Patient Safety Authority

Patient Safety Authority The Patient Safety Authority is an independent state agency of the Commonwealth of Pennsylvania
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We have received Pennsylvania Patient Safety Reporting System (PA-PSRS) reports of serious harm associated with a failur...
12/04/2023

We have received Pennsylvania Patient Safety Reporting System (PA-PSRS) reports of serious harm associated with a failure to adjust dosing upon reinitiation of clozapine therapy. Clozapine is an atypical antipsychotic approved for the treatment of treatment-resistant schizophrenia. Despite its clinical effectiveness, it is used as a last-line therapy and has risk evaluation and mitigation strategy (REMS) requirements because it can cause a number of serious and potentially fatal adverse effects such as agranulocytosis. Additionally, clozapine requires dose adjustments when used concomitantly with several categories of medications, such as CYP inducers and inhibitors, anticholinergic drugs, and drugs that cause QT interval prolongation.

In patients who have discontinued clozapine for two or more days, the manufacturer recommends the therapy be reinitiated at 12.5 milligrams once daily or twice daily to reduce the risk of hypotension, bradycardia, and syncope. Cases of severe cardiovascular effects have been documented in patients whose doses were not titrated appropriately after an interruption in therapy.

Learn more and share action items:https://patientsafety.pa.gov/NewsAndInformation/Documents/SAFETY%20ALERT%e2%80%94Clozapine.pdf

During routine rounds, a graduate nurse asked Jenny Rex how staff would perform CPR on a complex patient with severe spi...
12/01/2023

During routine rounds, a graduate nurse asked Jenny Rex how staff would perform CPR on a complex patient with severe spinal hyperextension. Rex and Dr. Adrian Zurca explored the literature and collaborated with the Simulation Center and the fabrication shop teams to design and create a custom backboard that would allow clinical staff to safely and effectively perform CPR for this patient. They tested the methods of providing compressions with the board and once the most effective approach was identified, Rex provided comprehensive hands-on training to clinical staff who cared for this patient to ensure proficiency in the techniques needed to use the board. When a resuscitation event required the use of the custom board and innovative CPR techniques, the patient experienced a positive outcome.

They won last year’s IAPS Individual Impact Award. If you know an individual or a team like them who made a significant impact on a patient or their facility, nominate them today for the I AM Patient Safety 2024 Individual Impact Award: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS2024.aspx But hurry—the nomination period ends this month!

This team sought to improve compliance rates of radiologist-recommended follow-up imaging studies by engaging the patien...
11/29/2023

This team sought to improve compliance rates of radiologist-recommended follow-up imaging studies by engaging the patient in their own healthcare. They collaborated with a startup software company to develop and implement a natural language processing algorithm and tracking-and-reminder system that identifies patients requiring follow-up imaging based on radiology reports, organizes follow-up recommendations by due date, and reminds patients of due or overdue recommendations via mobile text messages. This new automated system significantly improved rates of imaging follow-up, and subsequently improved patient care and outcomes. This workflow has been fully implemented to include all patients in the network.

They won last year’s IAPS Improving Diagnosis Award. If you know an individual or a team like them who enhanced the diagnostic process or made considerable effort to reduce diagnostic error, nominate them today for the I AM Patient Safety 2024 Improving Diagnosis Award: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS2024.aspx

We’re currently accepting submissions of original research articles, focused reviews, commentaries, quality improvement ...
11/28/2023

We’re currently accepting submissions of original research articles, focused reviews, commentaries, quality improvement studies, data analyses, patient perspectives, and other manuscripts that can help advance safety in healthcare.

PATIENT SAFETY is open-access, peer-reviewed, and included in major indexes such as Google Scholar and EBSCO. We have a quick turnaround: We are now on a rolling publication schedule, so when your article is accepted, it will be published as soon as production is complete—within weeks rather than months.

We look forward to reading your work. Send us your manuscript today at https://patientsafetyj.com/

The nursing staff at the Ambulatory Surgical Center and Infection Prevention teamed up to create a competency-based educ...
11/27/2023

The nursing staff at the Ambulatory Surgical Center and Infection Prevention teamed up to create a competency-based education collaboration. They designed an infection prevention training program for healthcare personnel and created measurable competencies, which contained observable skills and behaviors that one demonstrates as part of their job performance. To ensure that this education and training was translated effectively to practice, the team performed audits and encouraged feedback from staff. The goal was to promote adherence with standards of care and help sustain effective practices. Benefits of this intervention include building relationships between operating room clinical staff and the infection prevention department, maintaining compliance and creating a culture of safety.

They won last year’s IAPS Ambulatory Care/Surgery Award. If you know an individual or a team like them who advanced surgical safety, nominate them today for the I AM Patient Safety 2024 Ambulatory Care/Surgery Facility Award: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS2024.aspx

We're currently accepting nominations for this year’s 𝗜 𝗔𝗠 𝗣𝗮𝘁𝗶𝗲𝗻𝘁 𝗦𝗮𝗳𝗲𝘁𝘆 awards—but 𝗼𝗻𝗹𝘆 𝘂𝗻𝘁𝗶𝗹 𝗗𝗲𝗰𝗲𝗺𝗯𝗲𝗿 𝟭𝟲! Our prestig...
11/22/2023

We're currently accepting nominations for this year’s 𝗜 𝗔𝗠 𝗣𝗮𝘁𝗶𝗲𝗻𝘁 𝗦𝗮𝗳𝗲𝘁𝘆 awards—but 𝗼𝗻𝗹𝘆 𝘂𝗻𝘁𝗶𝗹 𝗗𝗲𝗰𝗲𝗺𝗯𝗲𝗿 𝟭𝟲! Our prestigious contest recognizes individuals and teams at Pennsylvania healthcare facilities; however, the Nationwide Warriors award, one of 10 available categories, is 𝗼𝗽𝗲𝗻 𝘁𝗼 𝗮𝗻𝘆𝗼𝗻𝗲 𝗶𝗻 𝘁𝗵𝗲 𝗨𝗻𝗶𝘁𝗲𝗱 𝗦𝘁𝗮𝘁𝗲𝘀.

Do you know someone who has shown a high commitment to patients and advancing safe healthcare? Share their story today at https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS2024.aspx

The I AM Patient Safety award is an annual contest that recognizes and celebrates healthcare staff for their individual or collective commitment to and influences on patient safety. It is a chance for us to celebrate the things that go right each day in healthcare to make our patients safer. We will...

Infectious disease epidemiologist Dr. Steffanie Strathdee and her husband, Tom Patterson, an evolutionary biologist, lov...
11/21/2023

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 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 and research into innovative treatments and therapies.

Read more:

By Caitlyn Allen. Infectious disease epidemiologist Dr. Steffanie Strathdee shares how bacteriophages—viruses that specifically target bacteria—can help us win the fight against antibiotic-resistant pathogens, including the one that almost killed her husband.

When it comes to patient safety, timing is important, which is why we’re making an exciting change to our journal: Effec...
11/16/2023

When it comes to patient safety, timing is important, which is why we’re making an exciting change to our journal: Effective immediately, PATIENT SAFETY is now on a rolling publication schedule, meaning we will publish articles online as soon as they are ready rather than hold them for quarterly issues.

We are pivoting our production model to share original research, quality improvement studies, and safety alerts with readers more quickly—so you can use the information sooner to keep patients safe. This dynamic approach will also keep you updated on trends and developments in healthcare as they are happening, so you can join the conversation instead of just reading about it.

Authors, when your manuscripts are accepted, you can expect to see them published within weeks instead of months.

Check out five brand-new articles now at https://patientsafetyj.com/issue/8315-vol-5-issue-3-rolling-2023
Be sure to sign up for updates so you don’t miss new article as they are published!

Help us celebrate healthcare workers whose efforts are making patients safer. Submit your I AM Patient Safety nomination...
11/14/2023

Help us celebrate healthcare workers whose efforts are making patients safer. Submit your I AM Patient Safety nominations by Dec. 16: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS2024.aspx

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.

𝘊𝘭𝘰𝘴𝘵𝘳𝘪𝘥𝘪𝘶𝘮 𝘥𝘪𝘧𝘧𝘪𝘤𝘪𝘭𝘦, known as 𝘊. 𝘥𝘪𝘧𝘧, is a bacteria (germ) that upsets your digestive tract. During 𝘊𝘭𝘰𝘴𝘵𝘳𝘪𝘥𝘪𝘶𝘮 𝘥𝘪𝘧𝘧𝘪...
11/13/2023

𝘊𝘭𝘰𝘴𝘵𝘳𝘪𝘥𝘪𝘶𝘮 𝘥𝘪𝘧𝘧𝘪𝘤𝘪𝘭𝘦, known as 𝘊. 𝘥𝘪𝘧𝘧, is a bacteria (germ) that upsets your digestive tract. During 𝘊𝘭𝘰𝘴𝘵𝘳𝘪𝘥𝘪𝘶𝘮 𝘥𝘪𝘧𝘧𝘪𝘤𝘪𝘭𝘦 Awareness Month read our Safety Tips for Patients on how to prevent infection: http://patientsafety.pa.gov/PATIENTSCONSUMERS/Pages/C.diff.aspx

PATIENT SAFETY is seeking submissions! Send us your original research articles, focused reviews, commentaries, quality i...
11/10/2023

PATIENT SAFETY is seeking submissions! Send us your original research articles, focused reviews, commentaries, quality improvement studies, data analyses, patient perspectives, and other manuscripts that can help advance safety in healthcare.

Edited and published by the Patient Safety Authority, our journal
√ has quick turnaround from submission to publication
√ is open-access, available online and in print
√ is double-blind peer-reviewed
√ is included in major indexes such as Google Scholar and EBSCO
√ is Patients Included™ compliant

Read our articles and submit your own today at patientsafetyj.com.

Look for exciting news next week about the future of PATIENT SAFETY!

This  , watch the Patient Safety Authority’s Q&A videos with medication safety experts for answers to questions like “"H...
11/09/2023

This , watch the Patient Safety Authority’s Q&A videos with medication safety experts for answers to questions like “"How do I know if something might be a side effect of a medication? And what should I do if I think I'm experiencing one?" and “What happens if I’m allergic to a medication? Is there any way to know upfront if I’m going to be allergic?” https://youtube.com/playlist?list=PLwJn-tgLXAJINLAygdyb5QocbAcDIiNUu&feature=shared

11/07/2023

This is , on the theme of “Who can report?” Learn how patients and healthcare workers can contribute to pharmacovigilance by reporting side effects and adverse drug reactions:

Happy Medical-Surgical Nurses Week! From November 1–7, AMSN & MSNCB reminds us of all the incredible things med-surg nur...
11/06/2023

Happy Medical-Surgical Nurses Week! From November 1–7, AMSN & MSNCB reminds us of all the incredible things med-surg nurses do, from improving patient care through evidence-based practice to advocating for patients and families.

Do you have a manuscript related to patient safety? Send it to our award-winning journal and it could be read by more th...
11/03/2023

Do you have a manuscript related to patient safety? Send it to our award-winning journal and it could be read by more than 75K readers worldwide: patientsafetyj.com. Accepted articles are published ~14 weeks from submission. There are NO FEES for authors or readers.

𝘌𝘭 𝘢𝘤𝘰𝘮𝘱𝘢𝘯̃𝘢𝘮𝘪𝘦𝘯𝘵𝘰 𝘥𝘦𝘭 𝘱𝘢𝘤𝘪𝘦𝘯𝘵𝘦 abarca temas de atención médica como qué hacer si le dicen que tiene una enfermedad crón...
11/02/2023

𝘌𝘭 𝘢𝘤𝘰𝘮𝘱𝘢𝘯̃𝘢𝘮𝘪𝘦𝘯𝘵𝘰 𝘥𝘦𝘭 𝘱𝘢𝘤𝘪𝘦𝘯𝘵𝘦 abarca temas de atención médica como qué hacer si le dicen que tiene una enfermedad crónica (de larga duración, a menudo incurable) o cuándo y cómo pedir una segunda opinión. (Consejo: no pasa nada si quiere consultarle a otra persona).

Nuestra esperanza, junto con la de muchos equipos de pacientes y trabajadores de la salud que nos han ayudado a escribirlo, es que, si todos podemos comunicarnos mejor, la propia atención médica también funcionarámejor.

Descargar gratis: https://patientsafety.pa.gov/PATIENTSCONSUMERS/Pages/Home.aspx

October is National   Month. Respiratory syncytial virus (RSV) is a common illness that often causes mild, coldlike symp...
10/30/2023

October is National Month. Respiratory syncytial virus (RSV) is a common illness that often causes mild, coldlike symptoms, with most people getting better in a week or two. Older adults are more likely to develop severe illness requiring hospitalization.

Adults at the highest risk for severe infection include the elderly, people with chronic heart or lung disease, people with weakened immune systems, and people living in long-term care (LTC) facilities. In the United States, about 60,000–160,000 older adults are hospitalized each year, and 6,000–10,000 die.

Learn how to protect against RSV and other respiratory illnesses:https://patientsafety.pa.gov/pst/Documents/Healthcare-Associated%20Infections/The%20Lowdown_Fall%202023.pdf

October is  , sharing the importance of patients being able to read, understand, and act on health information. One way ...
10/27/2023

October is , sharing the importance of patients being able to read, understand, and act on health information. One way to improve is through better communication between healthcare providers and patients.

We can help. Read our free pocket guide, 𝘛𝘩𝘦 𝘗𝘢𝘵𝘪𝘦𝘯𝘵’𝘴 𝘊𝘰𝘮𝘱𝘢𝘯𝘪𝘰𝘯, which explains how patients and clinicians can speak the same language and ask the right questions: https://patientsafety.pa.gov/PATIENTSCONSUMERS/Pages/Home.aspx

“I'm having a procedure tomorrow. Should I still take the same medications that I normally do?”Sharon Camperchioli, Phar...
10/26/2023

“I'm having a procedure tomorrow. Should I still take the same medications that I normally do?”

Sharon Camperchioli, PharmD, clinical pharmacist specialist/educator at Temple University Hospital, says, “That is a great question to ask anytime you are having a procedure. There is not one answer for all of those types of medications and procedures. Every procedure is unique in terms of what medications should not be taken around it.”

Watch and share:

"I'm having a procedure tomorrow. Should I still take the same medications that I normally do?"Institute for Safe Medication Practices (ISMP) fellow and emer...

10/24/2023

The Patient Safety Authority’s multiple award–winning, peer-reviewed journal has more than 75K readers in 174 countries—and counting! Every article is free to read and there are no author fees for submissions. Read the journal at patientsafetyj.com and send us your best work for publication.

PATIENT SAFETY is currently open to research articles, quality improvement studies, focused reviews, patient perspective...
10/23/2023

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. https://patientsafetyj.com/about

International Infection Prevention Week, October 15–21, celebrates the importance of infection prevention and the role o...
10/20/2023

International Infection Prevention Week, October 15–21, celebrates the importance of infection prevention and the role of infection preventionists in protecting public health. Read and share these articles highlighting measures hospitals and long-term care facilities can take to protect their patients and staff: https://patientsafetyj.com/post/2205-international-infection-prevention-week-2023

International Infection Prevention Week celebrates the importance of infection prevention and the role of IPs in protecting public health. Read these articles to learn more.

Get the lowdown on respiratory threats this fall, including respiratory syncytial virus (RSV) and the flu, and how to pr...
10/19/2023

Get the lowdown on respiratory threats this fall, including respiratory syncytial virus (RSV) and the flu, and how to protect long-term care residents and staff from infection. Read and share:https://patientsafety.pa.gov/pst/Documents/Healthcare-Associated%20Infections/The%20Lowdown_Fall%202023.pdf (PDF)

Nominations are open for the I AM Patient Safety 2024 Achievement Awards!This is your chance to tell the world about Pen...
10/18/2023

Nominations are open for the I AM Patient Safety 2024 Achievement Awards!

This is your chance to tell the world about Pennsylvania healthcare workers who have demonstrated their commitment to patient safety, by nominating them for an award in one of 10 categories: Ambulatory Care/Surgery Facility, Improving Diagnosis, Individual Impact, Long-Term Care Facility, Nationwide Warriors (open to any individual, team, or facility in the U.S.), Physician Offices, Safety Story, Sepsis, Time-Outs, and Transparency and Safety in Healthcare.

Submit your nominations by December 16, 2023, and help our 11th annual IAPS contest be the best one yet! Learn more: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS2024.aspx

During this year’s International Infection Prevention Week (IIPW) October 15-21, 2023, APIC celebrates the fundamentals ...
10/17/2023

During this year’s International Infection Prevention Week (IIPW) October 15-21, 2023, APIC celebrates the fundamentals of infection prevention and the basics that keep us all safe. Learn more: https://bit.ly/IIPW2023

"Why are there some medications you're supposed to take with food and others you're supposed to take on an empty stomach...
10/12/2023

"Why are there some medications you're supposed to take with food and others you're supposed to take on an empty stomach?"

Michelle Bell, BSN, RN, director of Outreach and Education with the Patient Safety Authority, says, “It has to do with how the medication is developed and made to be absorbed by your body. When you have food in your stomach, it changes the way that the medication is absorbed, so it could get absorbed in a different part of your stomach or get absorbed faster or slower.”

Watch and share:

"Why are there some medications you're supposed to take with food and others you're supposed to take on an empty stomach?"Institute for Safe Medication Pract...

Falls are the leading cause of ER visits in infants. But how to prevent them often isn’t discussed with new parents.Acco...
10/10/2023

Falls are the leading cause of ER visits in infants. But how to prevent them often isn’t discussed with new parents.

According to the CDC, pediatric falls result in about 8,000 emergency room visits every day and account for 50% of nonfatal injuries in infants. All infants are at risk for falls, and the number one risk factor is a tired parent—and what new parent isn’t exhausted all the time?

The good news is that infant falls are preventable.

Watch and share this video, produced in collaboration with UPMC Magee-Womens Hospital, to understand the risks and learn how to protect against them:

Falls are the leading cause of ER visits in infants. But how to prevent them often isn’t discussed with new parents.According to the CDC, pediatric falls res...

Pharmacists play a critical role in patient safety by serving as an information source to staff and patients, evaluating...
10/06/2023

Pharmacists play a critical role in patient safety by serving as an information source to staff and patients, evaluating medication suitability, identifying potential adverse effects, and promoting medication adherence.

In this recorded webinar, Megan Scheid, PharmD, medication safety officer at Reading Hospital of Tower Health; Jennifer Kunkel, PharmD, medication safety officer at Jefferson Health-Abington; and Christopher Walsh, PharmD, medication safety pharmacist at Penn State Health St. Joseph Medical Center, discuss strategies their institutions have implemented to best leverage this key member of the care team.

Watch and share:

Pharmacists play a critical role in patient safety by serving as an information source to staff and patients, evaluating medication suitability, identifying ...

The CDC says that now is the best time to get your flu shot, so schedule that appointment by the end of October to get m...
10/04/2023

The CDC says that now is the best time to get your flu shot, so schedule that appointment by the end of October to get maximum protection this flu season. Watch this video and join us in knocking out the flu!

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 ...

10/03/2023

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.

10/02/2023

October is , which highlights the importance of patients being able to read, understand, and act on health information. One way to improve is through better communication between healthcare providers and patients.

We have a tool to help: 𝘛𝘩𝘦 𝘗𝘢𝘵𝘪𝘦𝘯𝘵’𝘴 𝘊𝘰𝘮𝘱𝘢𝘯𝘪𝘰𝘯 offers tips to help patients and clinicians share information and ask the right questions. Download this pocket guide at http://patientsafety.pa.gov/PATIENTSCONSUMERS/Pages/Home.aspx and share it with your loved ones.

09/29/2023

If you missed our webinar yesterday covering everything you always wanted to know about peer review for scientific journals, here's a recording of the presentations by PATIENT SAFETY managing editor Caitlyn Allen, MPH, and author/editor/peer reviewer Zane Wolf, PhD, RN, professor of Nursing Programs and dean emerita at the School of Nursing and Health Sciences, La Salle University.

Please watch and share!

09/28/2023

Sepsis (sometimes called “blood poisoning”) is when your body goes haywire trying to fight an infection. This extreme response can be life-threatening, but the sooner your care team finds it, the easier it is for them to treat it.

Sepsis can be difficult to diagnosis because a lot of the symptoms are similar to symptoms of other diseases. However, these are the most common ones, so tell your doctor if you have any of them: fever, feeling extra tired (“fatigue”), nausea, or a fast heartbeat.

Read THE PATIENT'S COMPANION for more information on , how to prevent it, and how to make sure it’s treated as quickly as possible: http://patientsafety.pa.gov/PATIENTSCONSUMERS/Pages/Home.aspx

It’s  , celebrating the essential role of peer reviewers in scholarly research and publishing.Want to know more about th...
09/27/2023

It’s , celebrating the essential role of peer reviewers in scholarly research and publishing.

Want to know more about the peer review process and what it brings to journals? Join us tomorrow, Sept. 28, at 12 p.m. ET for a live conversation with editors, authors, and peer reviewers.

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