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Class III Obese Patients: The Effect of Gait and Immobility on Patient Falls1112331009/1/2013 6:00:00 AMFallsPennsylvania Patient Safety Authority (USA)This alert discusses the patient safety incidents that occur with Class III obese patients who have gait and immobility issues. Class III obese patients are identified as having a body mass index (BMI) greater than 40 or weighing 100 pounds or greater than their ideal body weight.7/27/2015 11:03:22 AM7http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Aspirin for the Prophylaxis of Venous Thromboembolic Events – To Use or Not To Use1126032385/30/2014 6:00:00 AMSurgeryOregon Patient Safety Commission (USA)This alert discusses the prevention of patient safety incidents of deep vein thrombosis (DVT) or venous thromboembolism (VTE) in orthopedic surgery with the use of acetylsalicylic acid (Aspirin®). Guidelines from both the American Academy of Orthopedic Surgeons (AAOS) in 2011 and the American College of Chest Physicians (ACCP) in 2012 addressed the use of Aspirin®and other prophylactic measures. Additionally, the Surgical Care Improvement Project (SCIP) has recently included Aspirin® to the list of pharmacological prophylaxis choices for preventing DVTs as of January 1, 2014. Although the evidence has not demonstrated a consistent benefit in the reduction of VTE after total knee arthroplasty, total hip arthroplasty, or hip fracture surgery in patients receiving Aspirin® and recent clinical trials have not shown a decreased risk of bleeding from Aspirin® compared to other anticoagulants, pharmacologic prophylaxis that may include Aspirin® should be considered for the prevention of DVT/VTE in orthopedic surgery to assure safe and highly reliable care. A recommendation is made to develop a VTE prevention standard and identifies necessary parameters.7/22/2015 5:52:07 PM6http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Quarterly Update on Wrong-Site Surgery: How to Do an Effective Time-Out in the Dark1126932306/1/2014 6:00:00 AMSurgeryPennsylvania Patient Safety Authority (USA)This update includes a quarterly update of the reports of wrong-site surgery in Pennsylvania and a failure mode and effects analysis of time-outs for laser procedures on eyes. There were 10 reports of wrong-site surgery in Pennsylvania operating rooms (ORs) during the first quarter of 2014, the third consecutive quarter of the academic year with 10 reports. Anesthetic blocks administered at the wrong location continue to be the most common wrong-site procedure reported from Pennsylvania operating suites. Two reports of stents placed in the wrong ureter were added to the 19 prior reports. For the eighth time in 10 years, a report was received that a surgeon made an incision for a carpal tunnel release on a patient who was to have a trigger finger release. Incorrect or inadequate information received from the surgeon’s office with respect to the OR schedule or consent accounted for 9% of all wrong-site surgical procedures— 1 out every 11. Consents continue to be obtained with incorrect or missing laterality. The wrong charts sometimes accompanied the patients. Late changes in plans continue to result in misinformation when all possible sources of information are not uniformly updated. Marking of the site without prior reconciliation of the supporting documents and correction of the latter in a timely manner contributed to a patient safety incident. The white board in the OR was a source of incorrect information according to one report. Descriptions of patient safety incidents of each type of wrong-site surgery are provided as well as recommendations to prevent the category of incidents described. The alert also discusses the use of a time-out in an ambulatory surgical facility involving laser eye surgery. Laser eye procedures are done in a room that is dark, with only one room light. In the facility observed, the one light was recessed in the ceiling and is on a dimmer switch managed by the nurse and adjusted to the surgeon’s preference. The patient’s chin and forehead rest against the laser machine, which blocks the face and makes it impossible to see the site marking. Despite the challenges, a successful time-out was still possible. The alert provides recommendations for a time-out in laser eye surgery.7/22/2015 5:52:07 PM3http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Peripheral Vascular Catheter–Related Infection: Dwelling on Dwell Time1127532243/1/2014 7:00:00 AMInfection ControlPennsylvania Patient Safety Authority (USA)This alert discusses the patient safety incidents of infection in patients with a peripheral intravenous catheter. Current recommendations for prevention of vascular catheter related infection allow for the catheter to be left in place for 72 hours or until clinical indications for removal are manifested. The Pennsylvania Patient Safety Reporting System and the National Healthcare Safety Network were searched for evidence related to the prevalence of peripheral intravenous catheter infection–related bacteremia and the related time frame of infection development. Focusing on Staphylococcus aureus (S. aureus) primary bloodstream infection (BSI) as a surrogate for the detection of peripheral intravenous catheter–related infection, there was an significant increase in primary BSIs 72 hours post-admission. S. aureus is the second most common cause of hospital-acquired BSI, and it has been estimated that as many as 76% of hospitalized adult inpatients have a PVC. Due to the high incidence in which peripheral catheters are used when caring for inpatients, complications like bacteremia may contribute substantially to yearly hospital-acquired infections. This alert challenges the recommendations based on review of bacteriemia associated with peripheral IV catheters both from an infection and cost control perspective. From an infection control standpoint, waiting for a clinical indication of infection to re-site may place the patient in a position for the development of bacteremia due to prolonged dwell times. Re-siting at 72 hours may reduce peripheral vascular catheter-related infection (PVCRI) risk, and a comprehensive approach to PVC care (including use of best practices for insertion, maintenance, and monitoring) is fundamental for the development of a peripheral vascular catheter (PVC) care program. Furthermore, re-siting of PVCs inserted in the field or emergency department, avoiding the antecubital fossa, and limiting dwell time (daily review of necessity) may help prevent PVCRI even further. In assessing cost effectiveness of not replacing the PVC every 72 hours and based on an average length of stay of 5.4 days, the argument of cost savings related to abandoning scheduled replacement of PVCs does not add up. The data, at least in Pennsylvania, seems to indicate that patients are at risk for PVC related bacteremia after a PVC is in place past the 72-hour mark. Recommendations for infection reduction for the adult patient with a peripheral intravenous catheter are provided.7/7/2015 9:11:36 AM6http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
The Use of Patient Sitters to Reduce Falls: Best Practices 1127632233/1/2014 7:00:00 AMFallsPennsylvania Patient Safety Authority (USA)This alert discusses the prevention of falls in high risk patients through the use of patient sitters. Patient sitters (also called patient safety assistants, companions, and one-to-one or constant observers) are staff or volunteers assigned to provide direct observation of patients at risk to harm themselves or others. Patient sitters are used in a variety of care settings, including for patients who are assessed to be at high risk for a fall; in psychiatric crisis, including those who have attempted suicide or with suicidal ideation, or at risk for harming others; substance-abusing with behavioral problems; or experiencing delirium, confusion, or agitation. Using patient sitters to directly observe patients at high risk for falls is a practice suggested as part of several evidence-based falls prevention guidelines. However, the clinical and cost-effectiveness of sitter programs has been questioned. Analysis of data from 75 hospitals participating in the Hospital and Healthsystem Association of Pennsylvania Hospital Engagement Network Falls Reduction and Prevention Collaboration revealed a statistically significant correlation (p < 0.05) between low rates of falls with harm and the use of sitter programs. A statistically significant correlation (p < 0.05) was also identified between low rates of falls with harm and three specific sitter program design elements: defining criteria for sitter qualifications, providing a training program for sitters, and establishing a pool of sitters. Analysis of falls reported to the Pennsylvania Patient Safety Authority by hospitals from across the commonwealth in which sitters were identified as being present at the time of the fall suggests that the use of sitters may be associated with a higher percentage of assisted falls and a lower rate of falls with harm. A review of the literature exploring the use of sitters as part of falls prevention programs, along with suggested strategies for sitter program design, are presented. A tool is provided to help hospitals make the business case for implementing and maintaining a sitter program. To off-set the cost of patient sitters, three scenarios are presented as options. One facility used psychiatric liaison nurses who acted as consultants for medical patient care areas in the use of patient sitters. Another hospital established safe units where patients who required frequent or constant observation were placed. Newly hired employees are required to attend an eight-hour SAFE class and were called a “constant observer” or “therapeutic companion,” since their roles were viewed as more active than just sitting with a patient. The third facility created a patient safety assistant position whose responsibilities were broader in scope than a patient sitter and included things like restocking supplies for the department, delivering specimens to the lab, transporting patients, and responding to call bells. Patient sitters are one of many interventions that facilities can use to reduce falls. When implementing a patient sitter program, hospitals are encouraged to incorporate specific best practices in sitter program design. To structure patient sitter programs, hospitals can engage in strategies found to be successful in reducing falls and controlling costs in other organizations. The cost savings achieved in decreasing rates of falls with harm, both in terms of money saved and decreased severity of injury, may justify the costs associated with implementing and maintaining a sitter program. Recommendations for the design of sitter programs are provided.7/27/2015 11:04:02 AM14http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
FALLS1128432171/1/2014 7:00:00 AMFallsMinnesota Hospital Association and Minnesota Department of Health (USA)This alert provides an update of the progress of preventing patient safety incidents of falls in Minnesota. In 2013, hospitals reported 81 falls that resulted in serious disability or death, an increase of three percent from the previous year. Ten patients died from injuries associated with their falls, an increase of one from the previous year. Overall, the most common serious injury sustained during a fall was a lower extremity fracture (most commonly leg or ankle fractures) making up 43 percent of the serious disabilities. Hip fractures, head injuries and upper extremity injuries accounted for an additional 54 percent of injuries. Injury risk factors for falls have been identified as patient age greater than 85, bone issues such as osteoporosis, if a patient is on anticoagulant therapy, and whether the patient is post-surgical. 69 percent of patients who were seriously injured from a fall had at least one injury risk factor and 90 percent of patients who died from those injuries had at least one injury risk factor. This leads to the conclusion that not only fall risk is important to assess, but injury risk as well. Two thirds of all patients who fell and sustained a serious injury were assessed to be at risk for falls and therefore should have had fall and injury prevention interventions in place. However, only 34 percent of patients were placed on a hi/low bed to keep them closer to the floor and in none of the 81 reported falls was there a floor mat in place to prevent fall related injury. Last year, falls occurring in treatment settings for behavioral health had nearly doubled. This year, more than 40 percent of falls were toileting related, most often occurring when a patient got up to use the toilet on their own without assistance. A quarter of all falls with serious disability or death occurred two days or less from the date of anticipated discharge. This may be attributed to the patients feeling better and stronger and overestimating their strength and balance, which can lead to a fall. Preventing falls will focus on injury risk screening and assessment and ensuring interventions to prevent falls or fall injuries are in place as well as to identify key interventions to prevent falls in the older adult population.7/27/2015 11:03:52 AM4http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Correct Usage of Fume/Vapour Soaking Solutions1137131331/20/2014 7:00:00 AMInfection ControlNew South Wales Department of Health (Australia)This Safety Information provides advice to health services of the functional limitations of fume/vapour soaking stations (such as the GUS® System). Fume/vapour soaking stations facilitate the immersion of reusable medical devices such as flexible endoscopes and/or sonographic devices to bring them into contact with a liquid chemical disinfectant and eliminate fumes associated with approved liquid chemical disinfectants used in reprocessing. The high level disinfection occurs through the action of the active ingredient. Manufacturers’ instructions for the use of the fume/vapour soaking station and the active ingredient must be followed as well as any relevant work, health and safety instructions. Recommendations to minimize risk and prevent patient and staff safety incidents when using fume/vapour soaking stations are provided.7/7/2015 9:11:37 AM8http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Safe Use of Insulin Pens11376329012/16/2014 7:00:00 AMMedicationAlberta Health ServicesThis alert provides information on the safe use of insulin pens to avoid patient safety incidents. Insulin pens are injector devices containing an insulin cartridge or reservoir. These devices are used for subcutaneous insulin administration, either by health care professionals or by patients, and are available in both refillable and disposable pen formats. Unsafe use of insulin pens can result in harm to patients or staff and include practices such as the following: 1. Sharing of pens between patients resulting in a risk of cross contamination and exposure to blood borne pathogens such as HIV and hepatitis. 2. Incorrect use of a pen which may result in administering the wrong dose of insulin or a needle stick injury to staff. 3. Poor injection technique which may result in administering the wrong dose of insulin. The alert provides recommendations for safe practices utilizing insulin pens addressing the following: • Ensuring that insulin pens are used for only one patient • Use of safety needles • Reviewing the manufacturer’s instructions for use • Using safe injection techniques A “Frequently Asked Questions” section is included in this alert addressing the following questions: 1. Are there different types of insulin pens? 2. How do you use an insulin pen? 3. What are infection risks associated with insulin pen use? 4. What are insulin pen safety needles and how do you use them? 5. How do I order insulin pen safety needles? 6. Can I withdraw insulin from a cartridge using a needle and syringe? As well a list of educational resources, available through hyperlinks and including videos and brochures, are provided addressing a number of issues related to safe use of insulin pens. 7/7/2015 9:20:40 AM34http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Aggression in a long term care facility 11385328211/3/2014 7:00:00 AMPatient ProtectionManitoba HealthAn ambulatory PCH resident was kicked in the mid-section by a co-resident who was sitting restrained in a wheelchair by a front opening, side release seat belt. The resident in the wheelchair was known to become agitated and aggressive. The ambulatory resident fell backwards and fractured their left hip. The incident is believed to have occurred with minimal provocation; both residents have dementia. Distraction techniques such as a regular walking schedule may help reduce the tendency for agitation and aggression to escalate. Following lunch, clearing of the dining room seems to be a very busy time. The area just outside the dining room becomes congested at a time when minimal staff is present. Residents with dementia may benefit from greater one on one time with a volunteer or companion visitor. Additional events, such as musical entertainment and activity groups, scheduled on the unit may also allow for distraction. Residents with dementia have specific needs and activity requirements. Staff working on this unit would benefit from training and the development of skills to manage working in a high risk environment associated with managing multiple residents with dementia.7/7/2015 9:25:45 AM33http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Chart review of Fixed-Wing Medevac patients who landed at the Edmonton International Airport1139032911/12/2015 7:00:00 AMCare ManagementHealth Quality Council of AlbertaAs part of its monitoring role, HQCA independently conducted a review of the transport and care provided to medevac patients since the March 2013 Edmonton City Centre Airport (ECCA) closure. This review was conducted to determine implications for quality and patient safety as well as the outcomes for patients who received medevac services that landed at the Edmonton International Airport (EIA). Summary of findings: -No adverse patient safety or care issues were identified that could be associated directly with the relocation of medevac services to the EIA from ECCA. -There were eight deaths in the critically-ill cohort of 232 patients within the initial 24 hour period post-transport. No evidence was found that care or time elements of fixed-wing transport/EMS played any significant role in the death of these patients. - The transfer time from the EIA to the tertiary care hospital (University of Alberta Hospital or Royal Alexandra Hospital) represented approximately 15 per cent of the overall patient journey time. In comparison, the time it took to call for medevac / assistance after a patient arrived at the sending facility represented approximately 40 per cent of the overall patient journey time.7/7/2015 8:47:52 AM50http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse