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Pennsylvania Patient Safety Authority Marks Milestone With One Million Reports
Date:8/12/2009

porting events can help them learn and implement change to improve patient safety," Doering said. "Hospitals and ambulatory surgical facilities responding to our surveys made over 600 process changes in their facilities in 2008 in direct response to the report data analysis and guidance provided by the Authority."

Doering added that to date the Authority has published over 225 educational articles in its Patient Safety Advisory since 2004. A wide range of topics have been covered with national success. One article highlighting the risks of color coded wristbands sparked a national effort to standardize the meanings and colors.

In December 2005, the Authority published an article about a near miss in one of the facilities where a patient almost died because a nurse confused the meaning of a color coded wristband she placed on the patient. The nurse placed a yellow wristband on the patient thinking it meant "Do Not Take Blood from this Arm" when it actually meant "Do Not Resuscitate." Fortunately, the error was caught and the patient was resuscitated after suffering a heart attack.

The Authority did a survey of the number of colors and meanings facilities used for the wristbands and found there were several colors used by facilities with different meanings depending upon which hospital you were in.

"Shortly after the color coded wristband issue was published, healthcare facilities in northeastern Pennsylvania began to develop protocols for standardization. Those protocols have been adopted in 46 states throughout the country in some form," Doering said. "All states reference the near miss reported in Pennsylvania as the catalyst for making the change to standardize the meanings and colors of color coded wristbands."

Doering said the Authority also brought a national awareness to the issue of wrong site surgery. In June 2007, the Authority published an Advisory article highli
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SOURCE Pennsylvania Patient Safety Authority
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