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Patient Safety Authority Issues Annual Report for 2007
Date:4/30/2008

to the facility. In about 13% of reports where MRSA was found upon admission, the information about the infection was not communicated to other healthcare workers. Consumer tips for how the patient can help protect themselves against MRSA were included with this Advisory and have been distributed through other means.

-- Assessed volunteer users of electronic pharmacy systems in Pennsylvania. The study raised awareness that the pharmacy computer systems were not detecting all unsafe drug orders. The Authority encouraged all Pennsylvania facilities to test their systems to ensure all potentially harmful medication errors are caught.

-- Focused attention on the increased risks of anesthesia complications for patients with obstructive sleep apnea (OSA). OSA is a common sleep disorder that causes recurrent episodes of complete and partial airway collapse during sleep, resulting in the failure to breathe properly. Approximately 80-90% of patients with OSA are undiagnosed, but incorporating OSA into pre-surgical screening gives clinicians an opportunity to take steps to reduce anesthesia complications for these patients. Over 250 reports show OSA as a contributing factor for anesthesia complications. About 20% are considered Serious Events, including three deaths.

-- Continued focus on frequency of medication errors highlighting unclear and confusing labeling and packaging, as well as look-alike or sound-alike drug names as potential causes. The Authority offered guidance on how to minimize the risk by using technology such as bar coding and automated dispensing technology; requiring staff to double check the dose before administering; and monitoring patients closely before discharge.

The Authority's research findings are disseminated widely through the Patient Safety Advisories. The importance of distributing the Advisories to all appropriate healthcare facility staff cannot be emphasized enough so that the facility can benefit fully f
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SOURCE Pennsylvania Patient Safety Authority
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