Pennsylvania Patient Safety Authority Releases Septembe...(at success of the project depends upon a...),Health

A list of the anticipated benefits of the collaboration include a learning network for facilities in the northeast of Pennsylvania to help reduce and eliminate phlebotomy specimen mislabeling and new educational processes designed to eliminate common human behaviors that might cause an error to occur.

A complete list of the anticipated benefits is included in the 2009 September Pennsylvania Patient Safety Advisory article "Collaborative Patient Safety Effort: Addressing Phlebotomy Specimen Mislabeling." Future Advisory articles will also give updates on best practices identified within the collaboration.

The Authority's quarterly September 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:

• Medication Monitoring Errors: More than 2,500 event reports submitted to the Authority were specifically classified as errors involving drug-related clinical monitoring. Analysis shows that 48% of the events reached the patient. The medication most frequently involved in these reports was levofloxacin (416 events), a drug that requires dosage adjustments based on renal function. Strategies to address these problems are discussed along with valuable information provided by the facilities that helps pinpoint the exact causes of the errors.
• Connecting Remote Cardiac Monitoring Issues with Care Areas: Patients in noncritical settings may have underlying cardiac conditions or demonstrate unexpected symptoms and condition
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