College of American Pathologists
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What the reports say

Rolling out a statewide system for patient safety

April 2004
Karen L. Wagner

Pennsylvania's Patient Safety Authority issued its first advisory in early March.

During phase one of implementing its patient safety reporting system, 22 hospitals and ambulatory surgical and birthing centers submitted more than 2,500 reports, 21 percent of which reported patient falls; 26 percent, medication errors; 23 percent, errors related to procedures of any type; and 11 percent, complications related to procedures of any type. The remaining 19 percent was categorized as "other."

Among the findings: One health care facility reported a mixup in the abbreviation for a left total hip replacement procedure, or LTHR. In the patient consent form, the procedure was incorrectly abbreviated LTKR, or left total knee replacement. The patient and the surgeon noticed the error.

The database also includes two incidents in which magnetic resonance imaging was inadvertently ordered for patients who had a cardiac pacemaker. The tests were cancelled in both incidents.