Letter From the Editor
You may have looked at this issue’s cover and asked yourself what in the world zebras have to do with patient safety. Join Missy Adams and her husband, Solomon, on her journey to the correct diagnosis. (Hint: Sometimes it really is the zebra and not the horse.) These stories from patients are so informative and critical to keep patient safety moving in the right direction. If you are a patient or caregiver and have a story to share, send us your manuscript. Manuscripts may describe an event or events that didn’t go well but they may also describe the things that go right. We learn from both.
March is the month that we celebrate patient safety. It is a time to renew our spirit and resharpen our focus. In this issue we celebrate those healthcare workers who day in and day out demonstrate a powerful commitment to making care safe for all. When you live in the world of patient safety it is so easy to only see the wrong. The team at the Patient Safety Authority (PSA) reviews every account of unanticipated patient death and permanent harm that happens across the Commonwealth of Pennsylvania. The collective review of event after event can be more than depressing. Yet, I love my job. I love my job because we are constantly learning from those events to make improvements AND because for every bad event that happens, I know there are thousands that go right. There are doctors and nurses and techs and support staff that go to work every day to make a positive difference—and they do. The winners of our 2020 I AM Patient Safety Awards are proof of that and serve as an inspiration.
Also in this issue: Medication errors related to weight discrepancies are a longstanding issue identified by organizations such as the Institute for Safe Medication Practices and the PSA. In 2018, the PSA issued formal recommendations to weigh all patients using metric units. Sonali Muzumdar’s practice improvement paper highlights one organization’s strategies to decrease errors in patient weights. Raj Ratwani and co-authors discuss their exploration of vancomycin-related events and share a new safety self-assessment tool to support risk identification and organizational learning. Mary Ellen Mannix tells the harrowing journey of her son James’ short life and her call to advocacy that followed.
If you have research, improvement initiatives, or perspectives that contribute to our combined knowledge, please consider submitting your next manuscript to Patient Safety at patientsafetyj.com.