Patient safety: no harm, no foul?
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Deutsch, Ellen S., author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, December 2017
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Arthroplasty, Replacement -- adverse effects Bone Cements -- adverse effects Mandatory Reporting Patient safety Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- As we work together to improve patient safety, should we focus on provider error or patient harm? In 2006, the Pennsylvania Patient Safety Authority published a report of six intraoperative cardiac arrests (/ADVISORIES/Pages/200612_01b.aspx)that occurred during hip arthroplasties using bone cement to implant prostheses; five of those events were fatal. At that time, there were few similar reports in the literature, and what is now known as "bone cement implantation syndrome" was not well understood. Reporting these rare events through Pennsylvania's statewide reporting system allowed recognition of a pattern that might not have been evident at individual facilities. Considering the knowledge generally available at that time, providers may not have thought that there were any errors in these patient-care events, but they reported the events in compliance with Pennsylvania's reporting criteria of unanticipated patient harm and thereby contributed to enhancing future patient safety.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- Extent:
- 1 online resource (1 PDF file (3 pages)).
- NLM Unique ID:
- 101718773 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101718773