"The Authority's main goal is to educate facilities to help them prevent medical errors," McKee said. "With the data, study results and risk reduction strategies outlined in the Advisory, facilities can take another look at their own data available to them through the reporting system and implement any necessary changes to their discharge processes to improve patient safety in their own facilities."

Along with the Advisory article and prevention advice, the Authority also provides facilities with a sample checklist to help staff assess that all discharge items are completed before the patient leaves the hospital. A consumer tip sheet is also available for patients to ensure they know what to expect at home before they leave the hospital.


For more information on the essential components of a discharge process and other risk reduction strategies go to the Pennsylvania Patient Safety Advisory article: "Care at Discharge-"Critical Juncture for Transition to Posthospital Care" go to the Authority's website at www.psa.state.pa.us.

The Authority's quarterly 2008 June Pennsylvania Patient Safety Advisory contains more articles developed from data submitted through real events that have occurred n Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions.

Highlights in the June 2008 issue include:

- Hypothermia Before, During or After Surgery Increases Risks to Patients: More than 50 reports have been submitted to the Authority that show patients experiencing hypothermia before, during or after surgery. Few reports showed any measures in place to prevent the hypothermia. Elderly patients and children are most at risk of harm if hypothermia does occur. Risk reduction strategies are provided for facilities to consider.

- Sterile Water Poses Risks, Even Death If Given Intravenously: The Authority has received reports that show a failure among healthcare practitioners to recognize the danger of giving patients sterile water intravenously to treat patients with high levels of sodium in their blood. Bags of sterile water are being mistaken for IV solutions which can result in patient harm and even death. Recognizing the problem and developing protocols to treat patients with high sodium in their blood are some of the risk reduction strategies for facilities to consider.

- A Tear or Hole Made During A Routine Colonoscopy Can Be A Serious Complication: A review of studies in the medical literature involving tears or holes (or colon perforations) made during routine colonoscopies show the risk may be reduced if certain factors are identified prior to surgery.

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