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Abbreviations: A Shortcut to Medication Errors11229PA01501/03/2005 7:00:00 AMMedicationPennsylvania Patient Safety Authority (USA)This Patient Safety Advisory discusses medication patient safety incidents that occur as a result of using confusing abbreviations and non-standard dose designations. A number of patient incidents are described and recommendations to mitigate risk provided.07/07/2015 9:22:37 AM
Prevention of Inadvertent Perioperative Hypothermia11310PA10801/06/2008 6:00:00 AMSurgeryPennsylvania Patient Safety Authority (USA)"Perioperative hypothermia may result in serious cardiac, coagulation, and wound-healing complications, especially among vulnerable pediatric and elderly patients. Many patient safety incident reports involved hypothermia that was detected in the postanesthesia care unit. Only a few reports indicated that measures were in place to prevent hypothermia. Contributing factors to hypothermia in the OR include exposure of a large body surface area to the typical low temperature and humidity in the OR environment, administration of cold IV fluids, evaporation from surgical sites, administration of unwarmed irrigation fluid, and use of certain skin preparation methods that result in evaporation. Actions to reduce risk in preventing perioperative hypothermia include assessing the patient for increased risk of hypothermia, monitoring temperature throughout the perioperative period using optimal temperature monitoring sites, and using active and/or passive warming measures as appropriate. More information regarding at risk populations as well as complications of inadvertent hypothermia are also included in the alert. Professional societies including AS a, the American Society of PeriAnesthesia Nurses (ASPAN) and AORN have provided their recommendations for the preoperative, intraoperative and postoperative period in this alert. "22/07/2015 5:54:37 PM
Choking Incident11044328801/11/2014 6:00:00 AMCare ManagementManitoba HealthNursing staff were alerted by another PCH resident that a co-resident may be choking in the dining room. The resident was found in the dining room, slumped in a chair, choking on what appeared to be a doughnut. A bag of scotch mints was also found on the lap of the choking resident. The resident’s airway was manually cleared. Emergency Medical Services (EMS) was called. The resident was found to be deceased. The resident had a history of taking food from other residents and also from the fridge in the dining room if it was left unlocked. A choking risk was identified in their health record. Their diet was to be restricted to items that were “soft/easy to chew”. The resident had a history of impulsive behaviors and lacked insight into their behavior. Residents have access to foods that are not within many of their dietary restrictions. There is a vending machine located on the main floor of the long term care facility that contains many foods that would pose a choking risk for some residents. The resident was identified as being at risk for choking as well as known to behave impulsively when food was present. For example, the resident would shovel food in quickly or take food from other residents. There is supervision in the dining room during scheduled meal times only. This event took place outside of a regular meal time. The resident was in the dining room unsupervised. Policy allows for residents and/or their family members to sign a waiver permitting them/their family member to have diet choices outside of their recommended diet order.07/07/2015 8:47:51 AM
Aligning the Lines: An Analysis of IV Line Errors10713322201/03/2014 7:00:00 AMMedicationPennsylvania Patient Safety Authority (USA)This alert discusses the patient safety incidents involving intravenously administered medications. From July 2004 through August 2013, Pennsylvania healthcare facilities reported to the Pennsylvania Patient Safety Authority 907 events of intravenous (IV) line errors. The reports were evaluated to determine what factors are associated with IV line medication errors. This analysis of IV line event reports offers an exclusive interpretation of IV line errors in Pennsylvania healthcare facilities, identifies common steps in the administration process where errors occurred, identifies medications most commonly involved in IV line errors, and categorizes factors associated with such errors. The most common errors occurred during setup and included rate of infusion mix-up or line mix-up (22.6%), IV lines not attached to patients (14.6%), and errors associated with piggyback infusions (12.8%). Of the reported events, 11.1% involved patients under the age of 18. High-alert medications were prescribed in 71.0% of all events. Heparin was the high-alert medication most frequently involved in an event error (16.6%), followed by insulin (7.6%) and parenteral nutrition (5.2%). Intensive care units (30.2%) ranked highest among all units where IV line errors were reported, followed by medical-surgical units (14.1%) and telemetry units (6.6%). High-alert medications were involved in 91.9% of IV line mix-ups. The medication most frequently involved in this type of event was heparin (26.7%). High-alert medications accounted for two-thirds (66.7%) of all events in which lines were not attached to the patient. The top three medications involved in these errors were: heparin (16.7%), morphine (8.3%), and insulin (6.1%). Heparin was the most common medication involved in piggyback administration errors (10.3%). Nearly half of the reports (48.1%) were categorized as harm score D or greater (as defined by the National Coordinating Council for Medication Error Reporting and Prevention), which indicates they reached the patient and required some type of intervention. While it is difficult to determine the exact causes of reported events, more than half of the submitted events involved the setup of IV lines. While more than twenty categories of error were identified from the Authority reports, the risk reduction strategies presented focus on reported events that comprised the top 50% of errors. Risk reduction strategies focused on setting up infusions completely and one at a time, administering high-alert medications as primary infusions, utilizing infusion sets with back-check valves, labeling lines, limiting pump setup to qualified and credentialed personnel, placing IV pumps and epidural pumps on opposite sides of the patient’s bed, and raising awareness of the risk of IV errors. Specific strategies are identified in the "Recommendations" section of this alert summary. A related finding in doing the research on IV medication errors revealed interesting information on the use of smart pumps. To date, there are no conclusive interventions to prevent these types of errors. Though practitioners rely on smart infusion pumps to alert them to errors, the safety mechanisms of smart pumps are limited. One study looked at type, frequency, and severity of medication errors associated with IV pumps and revealed that only 1 in 389 documented errors would have been prevented by smart pump technology. The study also points to the limited ability of smart pumps to prevent errors during the medication-use process, asserting that smart pumps are limited to preventing errors as a result of incorrect programming, which can result in a wrong dose (which does not match the order), wrong medication, wrong patient, or wrong indication. Specific patient safety incidents are described to illustrate the various types of errors involving infusion of IV medication.07/07/2015 9:20:37 AM
Impact of Implementation of Evidence- Based Best Practices on Nursing Home Infections109187503/09/2012 6:00:00 AMInfection ControlPennsylvania Patient Safety Authority (USA)This alert discusses the impact of various levels of implementation of infection prevention best practices on healthcare associated infection rates and discusses patterns of care that could be targeted for improvement and avoidance of patient safety incidents. Reports of inconsistencies in the implementation of evidence-based infection control best practices and the number of deficiency citations for infection control problems in nursing homes indicate the need to identify barriers to the integration of infection control practices in this setting. The Pennsylvania Patient Safety Authority conducted on-site assessment visits to 10 Pennsylvania nursing homes with high healthcare-associated infection (HAI) rates and 10 with low HAI rates. The assessment’s purpose was to study the impact of various levels of implementation of infection prevention best practices on HAI rates and to assess patterns of care that could be targeted for improvement. Authority analysts assessed the implementation of 50 evidence-based infection prevention best practices. The tool’s implementation categories associated with infection control program structure assessed the following: — Integration of best practices into the facility infection control plan, which is consistent with goals that are updated annually — Policies and procedures that reflect the facility infection control plan — Documentation of education provided on infection control goals and policies The tool’s implementation categories associated with infection control program clinical practice assessed the following: — Standard documentation methods in use — Monitoring, documentation, and evaluation of process and outcome measures — Assigned accountability and followup by managers and leaders Analysis of the aggregate assessment data from the visits demonstrated a relationship between high infection rates and low implementation of best practices. Compared with nursing homes with low infection rates, those with high rates were deficient in one or more of six levels of implementation for 45 of the 50 best practices. The assessments identified multidisciplinary implementation barriers in nursing homes with high HAI rates at the leadership, physician, clinical, and support staff levels and recognized patterns of care that nursing homes could target for improvement. Specific barriers reported included unavailability of alcohol-based handrub stations at the point of care, monitoring of antimicrobial use performed only at the pharmacy level, a lack of knowledge of aspiration prevention strategies, use of the outdated practice of routine changing and irrigation of Foley catheters, and refusal of physicians or residents to remove Foley catheters that do not meet evidence-based insertion criteria. Facility-wide barriers affecting all assessment domains included high acuity, low staffing, and limited consultant services. Infection prevention designees described lack of training, responsibility for multiple roles and multiple campuses, and lack of administrative support for infection control programs. Notable throughout the H-HAI survey results was an absence of structured and/or documented monitoring programs and communication strategies to involve and educate staff on infection issues and an absence of ownership of improvement projects, as well as a lack of infection control education for family members and residents. Limited space to separate clean and dirty items and unavailability of resources were also cited by H-HAI nursing homes as barriers to best-practice performance. Recommendations to prevent similar patient safety incidents are provided.07/07/2015 9:11:36 AM
Clopidogrel (Plavix) was not Prescribed After Percutaneous Coronary Angioplasty11092333201/10/2014 6:00:00 AMCare ManagementHong Kong Hospital AuthorityThis alert describes a fatal patient safety incident related to ineffective communication between caregivers from two different hospitals. A patient, with underlying diabetes, was admitted to Hospital A for acute coronary syndrome (ACS). The patient was referred to Hospital B for percutaneous coronary intervention (PCI) and drug eluting stents were implanted. Dual anti-platelet agent therapy (Plavix® and Aspirin®) for 1 year was planned. Upon discharge, patient was prescribed with the required medications for 3 weeks until the scheduled follow-up in Hospital A. During the two subsequent follow-up visits in Hospital A, the attending doctor managed only the patient’s insulin regimen; no follow up on the antiplatelet medication was conducted. One day after the 2nd follow-up in Hospital A, patient was admitted because of ACS and emergency investigation showed stent thrombosis. The patient died despite emergency PCI. The contributing factors to this incident included the following: 1. Communication breakdown between hospitals on post-PCI follow-up arrangement. 2. No formal departmental policy on follow-up arrangement for patients with PCI performed in another hospital. 3. Doctors unfamiliar with the post-PCI anti-platelet agent prescription were delegated to follow-up patients with PCI done in another hospital. Recommendations to prevent similar patient safety incidents are provided. 09/09/2015 11:16:14 AM
Problems Associated with Automated Dispensing Cabinets11312PA10901/09/2005 6:00:00 AMMedicationPennsylvania Patient Safety Authority (USA)"This Patient Safety Advisory discusses a number of medication patient safety incidents that can occur with the use of automated dispensing cabinets (ADCs). Cabinet design and use must be carefully planned and implemented to eliminate opportunities for wrong drug selection and dosing errors. The types of errors include wrong drug errors, stocking/ storage errors, and medications being administered to patients with a documented allergy. Contributing factors to errors include: - lack of pharmacy screening of medication orders prior to availability for administration. - excessive use of overrides in cabinets with patient profiling, placing the patient at risk of allergic reactions, drug interactions, and other hazards. - failure to recognize look-alike names in the design of an ADC’s alphabetic pick list or storage compartments, which can lead to choosing the wrong medication. - workarounds that include the removal of medications using the “inventory” function (designed to determine the current number of doses of a particular medication on hand) to gain access to medications for patients without pharmacy screening, removing a larger quantity of medications than ordered for one patient, and removing medications for multiple patients while the cabinet is open. - choosing the wrong medication from an alphabetic pick list for medication errors arising from medication names that look alike, - lack of a patient profile system within the ADC system - storing medications with look-alike names and/or packaging next to each other in the same drawer or bin. A common cause of these mix-ups is what human factors experts call “confirmation bias,” in which one “sees” what one expects to see."07/07/2015 9:22:39 AM
"C³ CORRECT PATIENT, CORRECT PROCEDURE, CORRECT SITE"11469UT00201/01/2006 7:00:00 AMSurgeryUtah Department of Health (USA)"This patient safety update describes the C³ Correct Patient, Correct Procedure, Correct Site process in detail and includes a copy of the patient brochure. "22/07/2015 5:56:00 PM
Patient Misidentification11792HK09801/10/2011 6:00:00 AMPatient IdentificationHong Kong Hospital AuthorityThis safety alert discusses two patient safety incidents related to incomplete patient identification. In one incident, a patient's domestic helper picked up the wrong drug basket for the patient. Dispensing staff issued ticket number 553 for the drug basket; the ticket produced was 563. The patient took the four medications not prescribed for them and later presented to the out-patient clinic with low blood pressure. Contributing factors in this incident were lack of concentration and misinterpretation between dispensing staff and the domestic helper. In the second incident, laboratory results showing a potassium level of 5.1 mmol/L for patient A were filed in patient B's record. A verbal order was given for Patient B for potassium chloride 10 mmol/L q8h. The error was discovered. Patient A's potassium level was checked and was 4.4 mmol/L. A contributing factor was considered to be non-compliance with the cross-checking procedure of patient identification.07/07/2015 9:25:31 AM
I’m Stuck and I can’t Get Out! Hospital Bed Entrapment11350PC0401/12/2006 7:00:00 AMBed Rail/RestraintPennsylvania Patient Safety Authority (USA)"In Pennsylvania, there were over 100 incidents, in just over two years, of patients becoming trapped in bed rails. Bed rails have their benefits, but their use or misuse can also place patients at significant risk, resulting in serious injury or death. Entrapment is an occurrence involving a patient who is caught, trapped , or entangled in the hospital bed, including the spaces in or around the bed rail, mattress, or bed frame. The alert discusses risk factors that are patient related, care related and equipment related. This alert describes actions to reduce risk. "07/07/2015 8:42:04 AM