Patient Safety Authority

10/31/2025

Join us on Thursday, January 8, 2026, at 1 p.m. EST for a free webinar, "Bullying in Healthcare: A Disruptive Force Linked to Compromised Patient Safety."

Bullying and disruptive behaviors in healthcare can undermine teamwork, communication, and trust, ultimately placing patients at risk. This webinar will examine how these behaviors affect patient safety and offer practical strategies to promote a safer, more respectful workplace environment.

Shirley Dominick, MSN, RN-BC, patient safety advisor at the Patient Safety Authority, will discuss bullying and how to recognize bullying behaviors, how these behaviors compromise patient safety, and strategies to address and reduce workplace bullying.

1.0 continuing education hours will be awarded for completion of this webinar; an application for Nursing Home Administrator (NHA) credits has been submitted and is pending approval.

Save your spot at this engaging educational session: cfdbf8f7-8f00-4c3f-825c-f78a6e031c0e@418e2841-0128-4dd5-9b6c-47fc5a9a1bde" rel="ugc" target="_blank">https://events.gcc.teams.microsoft.com/event/cfdbf8f7-8f00-4c3f-825c-f78a6e031c0e@418e2841-0128-4dd5-9b6c-47fc5a9a1bde

10/27/2025

Artificial intelligence (AI) is reshaping healthcare and expected to have a dramatic impact on patient safety as AI is further developed and refined. AI is expected to improve patient safety in key areas, such as by increasing efficiency of clinical decisions and care, reducing human error, offering risk prediction and early detection of change in patients’ condition, supporting system-level safety, and offering insights by aggregating many data sources.

Despite the optimism surrounding AI, the following patient safety concerns have been raised: AI models that are trained on biased or incomplete data, staff become overly reliant on and biased toward the recommendations provided by AI, staff not trusting the “black box,” AI has given erroneous recommendations for individual patients with incomplete and/or inaccurate records, staff are overwhelmed by being given too much information/notifications, and AI-based tools that are implemented prior to sufficient testing and validation.

Read more and share:

By Matthew A. Taylor. Artificial intelligence (AI) is reshaping healthcare and expected to have a dramatic impact on patient safety as AI is further developed and refined. AI is expected to improve patient safety...

10/23/2025

This week is International Infection Prevention Week (Oct. 19–25), organized by APIC - Infection Prevention and You. This year's theme is "Stand UPPP for Infection Prevention"—with UPPP standing for Unite, Protect, Prevent, Prevail.

In keeping with this call to collective action, PSA's fall issue of THE LOWDOWN, released today, celebrates how infection prevention and control is a team effort. IP is everyone’s responsibility within a facility, so this edition is dedicated to the ancillary departments​that are important members of the IP team.

Please read, print, and share this newsletter with everyone on *your* IP team: https://patientsafety.pa.gov/pst/Pages/Infection%20Prevention/thelowdown-fall2025.aspx

10/22/2025

We're hiring! The Patient Safety Authority has an opening for a Copy Editor (Communication Specialist). In this role, you will review content before publication, including but not limited to articles for our peer-reviewed journal, PATIENT SAFETY; PSA’s annual report; webinar slides; patient-facing materials; and newsletters. You may also develop content for PSA.

For more information and to apply, please visit https://patientsafety.pa.gov/PatientSafetyAuthority/Pages/Job_Openings_Links.aspx

We look forward to hearing from you!

10/20/2025

Everyone has an important role in patient safety, including admission registrars; nurses; physicians; pharmacists; environmental staff; and, especially, patients themselves. Share their inspiring stories by nominating someone (an individual or a team) for an I AM Patient Safety award.

Learn more and submit your nominations by Friday, November 21, 2025: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/2026-i-am-patient-safety.aspx

10/15/2025

The Patient Safety Authority recently received a report describing a fatal medication error that highlights persistent risks involving wrong drug events. In this event, a patient who was prescribed a medication typically used to treat high blood calcium levels inadvertently received a fatal dose of a neuromuscular blocking agent instead.

Read more:

By Myungsun Ro. The Patient Safety Authority (PSA) recently received a report describing a fatal medication error that highlights persistent risks involving wrong drug events.

10/10/2025

ICYMI: These days, it seems like generative AI is being integrated into everything—even in the setting of academic publishing. What are the pros and cons of scholarly authors, editors, and peer reviewers using AI tools?

In this discussion, recorded on October 1, 2025, 100% human Michael A. Bruno, MD, and editors from the Patient Safety Authority’s journal, PATIENT SAFETY, explore the current challenges facing academic journals—particularly regarding the peer review process—as well as the benefits and downsides of using AI in publishing workflows.

Watch & share:

These days, it seems like generative AI is being integrated into everything—even in the setting of academic publishing. What are the pros and cons of scholar...

10/08/2025

When a surgical team decides to collect a specimen for testing, this kicks off a complex process that involves many steps and many individuals across many disciplines. Specimen handling involves ordering, collecting, labeling, preserving, transporting, testing, and reporting results. The sooner this analysis is completed, the sooner the patient can be diagnosed and treated. However, such an involved, highly collaborative process is prone to problems along the way that can delay or prevent timely and appropriate treatment.

A multihospital healthcare network experienced two serious events that prevented a patient from receiving a diagnosis or treatment plan, one in which a specimen was lost and one in which a specimen was mislabeled. This network processes approximately 22,500 specimens quarterly with an error rate of 1.6 per 1,000 cases. Recognizing specimen handling as a problem-prone workflow, a quality team conducted a failure mode and effects analysis (FMEA) that identified 82 failure modes, including inconsistent workflows, workarounds, human factors, and knowledge gaps. The team focused on process improvements that would address the top 10 high-risk failure modes. Implementing and sustaining interventions guided by evidence-based practices—such as barcode tracking of specimens, use of read-backs to confirm orders and hand-offs, double checks, and education—in the operating room and gastrointestinal lab has resulted in zero reports of serious events.

Read and share:

By Sara Angelilli, Lisa Feathers & 1 more. Surgical specimen handling is a complex, multidisciplinary process that involves ordering, collecting, labeling, preserving, transporting, testing, and reporting results so a patient receives a diagnosis or treatment plan.

10/03/2025

Do you know someone who made a difference in the care and safety of a patient? Share their story by nominating them for an I AM Patient Safety (IAPS) award.

Submit your nominations by Friday, November 21, 2025, and join us in celebrating those who are advancing safe healthcare for everyone.

Learn more about the awards and nominate an individual or a team today: https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/2026-i-am-patient-safety.aspx

10/02/2025

Join us on Thursday, October 9, from 1 to 2 p.m. EDT, for a free webinar, "PCR Versus C&S Showdown: The Dilemma When Applying McGeer Criteria."

Understanding polymerase chain reaction (PCR) and culture and sensitivity (C&S) interpretation is essential for effective antimicrobial stewardship. T

Amanda Bennett and JoAnn Adkins, PSA infection prevention advisors, will guide participants in applying the revised McGeer criteria to accurately identify infections; address challenges such as colonization treatment, antibiotic misuse, and expression of resistance genes; and highlight the differences in how PCR and C&S results can inform decisions at both the patient and facility levels.

In this interactive and practical session, you will learn to analyze PCR and C&S results confidently, apply constitutional criteria, and understand the conditions necessary for identifying infections. 1.0 continuing education hours will be awarded for completion of this course. Continuing education credits apply to Pennsylvania registered nurses only.

Register now at de7fc46b-bf72-44d8-8347-93de59197bed@418e2841-0128-4dd5-9b6c-47fc5a9a1bde" rel="ugc" target="_blank">https://events.gcc.teams.microsoft.com/event/de7fc46b-bf72-44d8-8347-93de59197bed@418e2841-0128-4dd5-9b6c-47fc5a9a1bde

10/01/2025

There's still time to join us for this timely chat about AI in publishing, TODAY at 2 p.m. Email patientsafetyj@pa.gov for the Zoom link. Hope to see you there!

Tomorrow at 2 p.m., join Dr. Michael A. Bruno and editors from the Patient Safety Authority’s journal, PATIENT SAFETY, for an engaging, enlightening, and perhaps divisive conversation about the benefits of using AI in the publication process and its potential pitfalls.

E-mail patientsafetyj@pa.gov to receive the Zoom link to this free discussion and Q&A, and to submit questions in advance—or leave your questions in the comments below.

We're excited to see you!

09/30/2025

Tomorrow at 2 p.m., join Dr. Michael A. Bruno and editors from the Patient Safety Authority’s journal, PATIENT SAFETY, for an engaging, enlightening, and perhaps divisive conversation about the benefits of using AI in the publication process and its potential pitfalls.

E-mail patientsafetyj@pa.gov to receive the Zoom link to this free discussion and Q&A, and to submit questions in advance—or leave your questions in the comments below.

We're excited to see you!