Patient Safety Authority Releases Advisory Focusing on Common Causes of Medicat... (onepercent are considered serious events...)

Patient Safety Authority Releases Advisory Focusing on Common Causes of Medication Errors

Date:9/27/2007

one percent are considered serious events, or events that caused harm to the patient. One in four (25%) medication errors involve a high-alert medication.

Some other articles included in the 2007 September Advisory are as follows:

-- Potential dangers in behavioral health facilities: PA-PSRS reports indicate that patients continue to harm themselves in behavioral health facilities by using structures and objects in the behavioral health environment, particularly in patient rooms. Reviewing facility design, staff and family education, and patient assessment, may help minimize the risk. To view an interactive graphic of objects or structures in patients' rooms that have contributed to patient harm, go to the Authority's website at http://www.psa.state.pa.us.

-- Timeliness matters when transferring trauma patients: Pennsylvania healthcare facilities have submitted reports to PA-PSRS describing problems with transfers to trauma centers. The goal of a trauma system is to reduce the burden of injury to patients by ensuring that they receive the best care from the most qualified facilities as quickly as possible. Hospitals also save time with efficient transfers, but reports show more can be done to improve the delivery of patients from one facility to another.

-- Risks increased for patients with obstructive sleep apnea: Obstructive sleep apnea (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 OSA patients are undiagnosed. Over 250 PA-PSRS reports show OSA as a contributing factor for the event. About 20% of those are considered serious events, including three deaths. The reports included medical and surgical patients in both ambulatory surgical centers and hospitals. Learn more about the risk factors, signs and symptoms, diagnosis and treatment for OSA
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