Our Top 10 Most-Read Articles


Since we launched Patient Safety just 18 months ago, our journal has attracted 45,000 readers from 163 countries and garnered three awards for excellence. See what everyone has been reading—here are our top 10 most-popular articles!


A Brief Analysis of Telemetry-Related Events
Telemetry monitoring of heart rates and rhythms was introduced in intensive care units in the 1960s, and since then it has expanded into patient rooms and units in noncritical care settings. It allows healthcare workers to watch the condition of many patients all at once and intervene quickly when their condition changes; however, if the technology is not used appropriately or the equipment malfunctions, relying on telemetry monitoring also risks patient harm. A recent study looked at real-life cases of breakdowns in the processes and procedures regarding telemetry monitoring, such as user errors and miscommunication, and equipment failures, including broken transmitters and dead batteries. The lessons learned can help improve training and best practices to improve the safety of patients being monitored.

Read it at https://patientsafetyj.com/index.php/patientsaf/article/view/telemetry

Unplanned Extubation
Inserting an endotracheal tube (intubation) into a patient’s airway is a life-saving measure for those who are critically ill or injured, as well as a common practice for administering general anesthesia. However, the unplanned, uncontrolled removal of the tube (extubation), often by the patient, can cause grave harm, including aspiration pneumonia, arrhythmias, brain damage, and death. While complications with intubation have been widely documented, extubation largely has gone unstudied, especially related to intensive care units. In this study, two physicians examine the risks and offer strategies and resources for preventing this $5 billion per year problem.

Read it at https://patientsafetyj.com/index.php/patientsaf/article/view/extubation

What’s Your ONE Thing?
When the pediatric dermatologist called Kristin Aaron, she carefully wrote down one word on a Post-It Note: “histiocytosis.” The word didn’t mean anything to her at the time, but it soon would redefine her family’s entire life. Langerhans cell histiocytosis is a rare but deadly blood disorder—and a devastating diagnosis for Kristin’s 2-year-old son, Jenson. What followed were years of chemotherapy, as well as multiple healthcare-acquired infections. The tragic outcome inspired Kristin, and many others, to change patient safety, “one small step at a time.” In her own words, Kristin shares the emotional story of Jenson’s healthcare journey and asks everyone to “imagine if each of us picked one way to make it safer for patients, and that one thing turned into the next thing, and we started a patient safety revolution.”

Read it at https://patientsafetyj.com/index.php/patientsaf/article/view/kristin-aaron-commentary

Violence Against Healthcare Workers
Despite all the advancements in patient safety, safety for healthcare workers seems to be getting worse. According to the International Association for Healthcare Security and Safety Foundation, assault rates are at an all-time high since 2012, at a rate of 11.7 per 100 beds, and so is disorderly conduct, at 45.2 per bed. Other reports from around the United States show high rates of injury among healthcare workers, and that a significant number of these victims are working in fear—and there’s good reason to assume these incidents are grossly underreported. Patient Safety Authority Executive Director Regina Hoffman, MBA, RN, examines one of today’s biggest issues and raises the question: How can we reduce danger and violence in the workplace?

Read it at https://patientsafetyj.com/index.php/patientsaf/article/view/reducing-violence

Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities
Although wrong-site surgery (WSS) is considered a “never event”—a medical error or adverse event which is easily identifiable, is preventable, and has serious consequences for patients—it persists as a problem. In fact, every year, 74 patients experience a WSS—in Pennsylvania alone. WSS includes surgical errors involving the wrong anatomical side, the wrong site, the wrong procedure, and the wrong patient. Researchers studied 368 such events in the Pennsylvania Patient Safety Reporting System (PA-PSRS), reported by 178 facilities from 2015–2019, and provided a detailed breakdown by facility type, anatomical location, and more. This data highlights the ongoing challenge WSS poses and enables facilities to evaluate their own processes and develop strategies to reduce the likelihood of WSS, so that one day they will truly never happen.

Read it at https://patientsafetyj.com/index.php/patientsaf/article/view/wrong-site-surgery

2019 Pennsylvania Patient Safety Reporting: An Analysis of Serious Events and Incidents from the Nation’s Largest Event Reporting Database
Published in conjunction with Patient Safety Authority’s 2019 Annual Report, this article reviews and analyzes data from the Pennsylvania Patient Safety Reporting System (PA-PSRS). This close look into the 293,400 incidents and serious events reported by acute care facilities in 2019 provides valuable insights into patient safety in the Commonwealth and how we may continue improving it together.

Read it at https://patientsafetyj.com/index.php/patientsaf/article/view/acute-care-analysis-2019

Patient Safety Concerns in COVID-19–Related Events: A Study of 343 Event Reports From 71 Hospitals in Pennsylvania
Infection is only one way COVID-19 causes harm. Here’s what we know about how it was affecting patient safety six months into the pandemic, based on reports from 71 healthcare facilities throughout Pennsylvania. Looking at 343 events in the Pennsylvania Patient Safety Reporting System (PA-PSRS), one of the largest event reporting databases in the world, most events involved the emergency department, a medical or surgical unit, or the intensive care unit, and were commonly associated with errors in laboratory testing, process or protocol, and integrity of isolation. Familiarizing yourself with the data and knowing the facts are important in developing best practices to protect your patients.

Read it at https://patientsafetyj.com/index.php/patientsaf/article/view/patient-safety-concerns-covid19


Risk of Medication Errors With Infusion Pumps: A Study of 1,004 Events From 132 Hospitals Across Pennsylvania
Every day in every hospital, infusion pumps deliver vital medications and nutrients to patients. But what happens when these lifesaving devices stop working? The risk of medication errors with infusion pumps is well established, but to better understand the scenarios and factors associated with them, analysts studied the frequency of medication errors with infusion pumps in Pennsylvania. Among their discoveries: Most wrong rate errors led to medication being infused at a faster rate than intended, and user programming was the most common contributing factor.

Read it at https://patientsafetyj.com/index.php/patientsaf/article/view/infusion-pumps

Identifying Safety Hazards Associated With Intravenous Vancomycin Through the Analysis of Patient Safety Event Reports
Vancomycin is one of the most ubiquitous antibiotics used to treat infections, so it’s critical that every dose be administered correctly; however, intravenous (IV) vancomycin presents many unique complexities that must be well understood to keep the patient safe. To increase awareness of known IV vancomycin risk factors and help you determine how your facility may or may not be addressing them, we created the IV Vancomycin Safety Assessment Tool.

Read it at https://patientsafetyj.com/index.php/patientsaf/article/view/vancomycin

Prone Positioning in Patients With Acute Respiratory Distress Syndrome and Other Respiratory Conditions
Acute respiratory distress syndrome (ARDS) and respiratory failure—low levels of blood oxygen, resulting in shortness of breath, labored and rapid breathing, and perhaps low blood pressure, confusion, and fatigue—are common complications of infections like the flu and COVID-19. In the most severe cases, patients must be placed on a ventilator to breathe, and may be positioned face-down for 12 or more hours to alleviate pressure on the lungs and promote better oxygenation. However, remaining in a prone position for extended periods of time comes with its own health risks, including skin integrity injuries, such as pressure injuries, blisters, and skin tears; unplanned extubation; cardiac arrest; and dental and ophthalmologic issues.

Read it at https://patientsafetyj.com/index.php/patientsaf/article/view/prone-positioning