Patient Safety Authority

Everyone has an important role in patient safety, including admission registrars, nurses, physicians, pharmacists, environmental staff—and, especially, patients themselves. Share their inspiring stories by nominating someone (an individual or a team) for an I AM Patient Safety award. This year we have introduced new categories to highlight champions for their commitment to safety, solutions to address healthcare disparity, improving the medication administration process, and educating and engaging patients as partners in their own care. Learn more and submit your #IAPS2025 nominations by Saturday, January 4, 2025: https://lnkd.in/eRM3xJgN

As the end of the year approaches, we want to make sure you and your colleagues haven’t missed the latest research, news, and quality improvement studies from Patient Safety. Please take a moment to read and share these recently published articles. https://lnkd.in/gwYfx6yN

Do you know someone who made a difference in the care and safety of a patient? Share their story by nominating them for an I AM Patient Safety (IAPS) award. Submit your nominations by Saturday, January 4, 2025, and join us in celebrating those who are advancing safe healthcare for everyone. https://lnkd.in/eRM3xJgN

If you attended our Keys to Investigation webinars, don't miss this follow-up session, “Keys to Investigation: Now What?” on Tuesday, December 17, from 12 to 12:30 p.m. Melanie Motts, patient safety advisor at the Patient Safety Authority, will identify when an event investigation should be conducted and what resources and tools are needed to complete a thorough and credible event investigation, and explain how to utilize the investigation findings to enhance patient safety work. 0.50 continuing education hours will be awarded for completion of this course. Continuing education credits apply to Pennsylvania registered nurses only. Register now at https://lnkd.in/eZU_VMax

Our monthly newsletter keeps you up to date about what’s happening at the Patient Safety Authority, Pennsylvania facilities, and in healthcare today. In the December edition, you will read about a dangerous disorder that many people are unaware of, an emerging fungal infection that can spread in hospitals, an upcoming webinar on investigating events, and how event reporting has inspired change. Please read and share to help make healthcare safer for everyone: https://lnkd.in/eh_eiXqn

Healthcare providers in Pennsylvania play an important role in ensuring patients have the knowledge they require to make informed decisions. Effectively communicating appropriate details while addressing each patient’s unique needs and concerns remains a challenge for both providers and patients. In this recent webinar, Christopher Mamrol, BSN, RN, PSA patient safety advisor, defines health literacy, describes the scope and implications of the problem, identifies the barriers that patients and providers have when trying to address low health literacy, and outlines strategies to improve health literacy. Please watch and share: https://lnkd.in/eKAtxyPY

JUST PUBLISHED: While a rare occurrence, surgical instruments may break during a procedure. In the case of drill bits, which are one of the most frequently broken surgical instruments, pieces that are left inside of a patient could cause harm, and may migrate to other parts of the body. When Patient Safety Authority researchers noted an increased number of events involving broken and retained drill bits during surgery, they analyzed data from the Pennsylvania Patient Safety Reporting System (PA-PSRS) to help decrease the risk of broken drill bits in surgery. In studying cases involving a drill bit breaking during surgery, researchers learned that most of these events occurred during fracture repair procedures and joint replacement surgery, and drill bits most frequently broke in the femur (thigh bone). In most event reports, the broken drill bit was discovered during the procedure, but in 2.6% of event reports (4 out of 156 reports) it was discovered after the operation. Removing drill bit fragments is recommended; however, surgeons may decide to leave them in place if removal risks damage to the surrounding area, and in many event reports broken drill bits were retained following the surgery with no further intervention. Hospitals and surgical facilities should look to existing literature and device manufacturers’ guidelines for prevention strategies, such as recommended surgical techniques; drill bit sterilization, reprocessing, and storage; and general safety measures, some of which are summarized in the article. Please read and share: https://lnkd.in/eQQVfiC7

As part of their ongoing work to prevent and contain novel and targeted multidrug-resistant organisms, the Division of Healthcare Associated Infection Prevention (HAIP) in the Bureau of Epidemiology at the Pennsylvania Department of Health (DOH) has developed a 10-part video series on 𝘊𝘢𝘯𝘥𝘪𝘥𝘢 𝘢𝘶𝘳𝘪𝘴. Each video is three to 12 minutes in length and is intended to train healthcare personnel on this emerging fungus. In addition to videos targeted to any healthcare personnel type, there are videos in this series specifically intended for frontline nursing, physicians, environmental services staff, and laboratorians. The videos are available to view on the DOH website at https://lnkd.in/e6V7UCCd HAIP encourages healthcare leadership to incorporate these videos into their training plans for internal and external staff, as 𝘊. 𝘢𝘶𝘳𝘪𝘴 remains an urgent public health threat. Additional 𝘊. 𝘢𝘶𝘳𝘪𝘴 resources can be found at HAIP’s Healthcare Professional Resources page. You may reach their team at RA-DHHAI@pa.gov.

JUST PUBLISHED: In medicine, diagnosing a health problem is only the first step. In order to treat the illness effectively, you must understand what’s causing it. So it is with medical diagnostic errors; we know they are prevalent in the United States and can contribute to significant harm, as delayed or incorrect diagnoses can result in permanent disability or even death. But why do diagnostic errors continue to happen? To begin to answer this question, researchers looked at data about paid malpractice claims from 1999 to 2018 to identify what kinds of diagnostic errors are occurring and their frequency. In studying 226,718 reports in the National Practitioner Data Bank Public Use Data File, the authors found that diagnosis-related allegations accounted for the second-highest proportion of malpractice allegations, many of which were linked to disability or death. The top malpractice allegations included failure to diagnose, delay in diagnosis, wrong or misdiagnosis, and failure to order the appropriate test. Male patients were more likely to encounter diagnosis-related incidents, and the overall trend of diagnosis-related allegations associated with inpatients increased over the 20 years in the study. This analysis sheds some light on the characteristics and trends of diagnostic errors, which may help delve into the causes of diagnostic errors and the development of effective interventions to improve patient safety. Please read and share: https://lnkd.in/eenPWbV3

This recent webinar covers the current state of serious events involving newborns related to labor and delivery in Pennsylvania facilities and provides a deeper look into the most commonly reported event: shoulder dystocia. We review challenges related to shoulder dystocia cases and evidence-based practices for prevention and response when a shoulder dystocia occurs, as well as steps that can be taken after such an event, to inform practitioners with the aim of improving outcomes for future instances. Watch and share: https://lnkd.in/er8qJcty