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

ffers online training at http://www.psa.state.pa.us.

Wrong-Site Surgery Study

In June, the Authority held a press conference raising the awareness of wrong-site surgery, not only in Pennsylvania, but nationally as well. In September, the Authority visited several facilities to study why some facilities were better than others at preventing wrong-site surgeries. The wrong-site surgery study will continue as more information is obtained from facilities. For the complete Patient Safety Advisory article on the study and follow up go to the June 2007 and December 2007 Patient Safety Advisories at http://www.psa.state.pa.us.

Patient Safety Advisory Toolkits

The Authority also developed an educational toolkit with each Advisory as an additional resource for facilities to improve patient safety. The toolkits have covered topics such as preventing wrong-site surgery, decreasing the risk of medication errors in verbal orders, reducing the likelihood of skin tears and increasing hospital bed safety.

Outreach to Facilities and Providers

Authority staff and board members participated in numerous hospital-based educational programs throughout the year by making presentations to clinical staff about patient safety. Most audiences included physicians, nurses, pharmacists, other healthcare workers and administrators.

PSA Pharmacy Survey Project

In January 2007, 32 PA-PSRS facilities engaged in a statewide field test of hospital pharmacy systems. The study raised awareness that the pharmacy computer systems were not detecting all unsafe drug orders. Participating facilities received a report at the end of the survey that gave their facility's results along with the de-identified statewide results. The aggregate results were published in the March 2007 Supplemental Patient Safety Advisory and presented at the Patient Safe
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SOURCE Pennsylvania Patient Safety Authority
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