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Patient Safety Commission
Safety in Action Bulletins
Bulletins, Notices and "Pearls" / Safety Tips
Read reports, case studies and tips from Oregon facilities on improving safety
Click on the links below for more information about each bulletin, case or tip:
 
Confusing Labels - this bulletin discusses risks posed by confusing medication labels (August 2008)
 
Case Notes - this review highlights a hidden risk -- newborn babies who fall while being held by family or friends (August 2008)
 
Innovation and Safety – “low tech” surgical innovation with unanticipated results (July 2008)
 
Siderails and Bed Safety – information about entrapment and bed safety (March 2008)
 
Retained Objects – recommendations to avoid unintentionally retained objects during surgery (November 2007)
 
Case Study – a ‘good culture” nevertheless results in harm: lessons learned (November 2007)
 
INR Monitor – devices for testing levels of blood thinners are not all the same (November 2007)
 
Implanted Pain Pumps – adding medication to the pump requires precision (July 2007)
 
Sandbags & MRI – not all sandbags contain sand (May 2007)
 
Show Me the Mark – a quick second check of the surgical site before anesthesia (January 2007)
 
Ticket to Ride – information for patients transitioning in the hospital (November 2006)
 
Kinked Tubing – plastic tubing with a kink cannot be straightened (July 2006)
 
MRI Upgrade – more powerful MRI prompts re-evaluation of all equipment in MRI suite (June 2006)
 
 
Page updated: September 03, 2008

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