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

perating room. Surgical counts are intended to prevent the retention of a sponge, sharp or instrument during a surgical procedure, yet despite the methodical process, patients are still having items left inside of them after a procedure. This article details the processes of surgical counts and gives guidance for prevention of RFOs.
  • Medication Errors Occurring in the Radiologic Services Department: Nearly 1,000 event reports submitted to the Authority specifically mentioned medication errors that occurred in care areas providing radiologic services. This article explores the issue of medication errors in radiology with some surprising results. Risk reduction strategies are also given to prevent medication errors. Consumer tips are also available with information for patients on how they can protect themselves from medication errors.
  • Complications Related to Gynecologic Procedures: The Authority has received 376 reports of complications that occur during certain gynecologic procedures. The most commonly reported event is the puncture of organs (77%), most frequently the uterus (96%). This article details the information found in the data and gives risk reduction strategies for prevention.
  • Safety for Patients Receiving an MRI(magnetic resonance image): Objects becoming airborne in the MRI scan area can cause severe harm or even death to patients or others if these objects are not removed from the area prior to a magnetic resonance (MR) scan. Between June 2004 and December 2008 the Authority received 27 reports about magnetic objects becoming airborne in the MR environment, 16 magnetic items were brought into the MRI scanner room without becoming airborne and five magnetic items were almost allowed into the MRI scanner room. Proper techniques for scanning patients for magnetic items are discussed and protocols for identifying and labeling equipment that can and cannot be brought into the scanner room are also detaile
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  • SOURCE Pennsylvania Patient Safety Authority
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