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Pennsylvania Patient Safety Authority Releases June Advisory
Date:6/30/2009

infection seminar for ambulatory surgical facilities, a basic patient safety officer training program and have begun a hospital collaborative to reduce mix-ups of phlebotomy lab specimens," Doering said. "I expect the feedback to increase as facilities get used to having us around and additional liaisons are put in place. We're here to help facilities find the information they need to develop and implement successful programs like the VAP programs at Roxborough and St. Christopher's."

"There's so much information out there that facilities most likely don't have to reinvent the wheel, but simply tailor the success of others to meet their facility's needs," Doering added.

For more information about the VAP programs at Roxborough or St. Christopher's Hospital for Children go to the 2009 June Pennsylvania Patient Safety Advisory at www.patientsafetyauthority.org.

The Authority's quarterly June Advisory contains other articles developed from data submitted about real events that have occurred in Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions. Highlights include:

  • Preventing Retention of Foreign Objects (RFOs) in a Patient: Leaving objects inside of a patient after surgery can often lead to serious injury. In 2008, the Authority received 2,228 reports involving an incorrect sponge, sharp or instrument count. Of the reports, 1,040 (47%) involved incorrect needle counts, 731 (33%) involved incorrect equipment counts, and 454 (20%) involved incorrect sponge counts. During that same one-year period the Authority received 194 reports of RFOs reported as a separate event category. Of those reports, 160 (84%) indicate that a radiograph was done. In 43 (22%) reports, the RFO was discovered after the patient left the o
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SOURCE Pennsylvania Patient Safety Authority
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