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Tubing Misconnections: Making the Connection to Patient Safety11245PC166/1/2010 6:00:00 AMDevicePennsylvania Patient Safety Authority (USA)"Some patients may have multiple tubing lines connected to them for reasons such as delivery of medication and nutrition therapy. With these multiple lines, the potential for tubing misconnections becomes more prevalent. Tubing misconnections can occur with intravenous catheters, feeding tubes, hemodialysis tubes, and tracheostomy cuffs, among other devices. One of the main reasons for tubing misconnections is that many types of tubing for different types of medical devices incorporate luer connectors. These connectors contribute to misconnections because they allow functionally dissimilar tubes or catheters to be connected together. Specific serious patient safety incidents involve a 4 week old infant who did not receive a bolus of Normal saline because the connection bypassed the infusion pump, a patient was scheduled for an MRI with both an IV site and a tracheostomy. When the MRI was initiated, the radiologist noted that no signs of contrast. It was discovered that the contrast was inadvertently injected into the tracheostomy cuff and not the patient's IV site. This Patient Safety Advisory focuses on liquid-to-liquid and liquid-to-gas tubing misconnections. Actions to reduce risk which include equipment design and administrative controls, have been provided and through tubing and enteral feeding misconnections."7/7/2015 9:07:14 AM38
"AEDPlus Public Access Automated External Defibrillators (AEDs), manufactured by Zoll."11400VA473/1/2009 7:00:00 AMDeviceNational Center for Patient Safety (Department of Veteran's Affairs - USA)"The affected defibrillators’ batteries can have a shorter than expected life, expiring after three years, rather than five. When used in defibrillation, the device may verbally prompt users to “change batteries” and fail to deliver therapy. There will be no prior warning of the failure. This alert affects all AEDPlus defibrillators sold before March 2009. The AEDPlus is distributed in many areas, both clinical and administrative. Additionally, they are distributed to VA in general, including VACO, VBA, VCA and OI&T offices. The Alert describes actions to be implemented by applicable VA facilities. "7/7/2015 9:07:36 AM4
"Delay in diagnosis of a patient's malignancy as a result of ineffective information exchanges between an Emergency Department, dialysis department, and primary care physicians"11577WRHA83/1/2008 7:00:00 AMCare ManagementWinnipeg Regional Health Authority (Canada)"A delay in diagnosis of a malignancy as a result of ineffective information exchanges between an Emergency Department (ED), dialysis department, and primary care physicians. The patient visited the ED over 20 times within a 5-month period for the same symptoms. Roles and responsibilities of care providers in the transition of patient care from hospital to primary care and the reverse are not well-defined."7/7/2015 8:58:39 AM6
Improving Vasopressor Safety1086431501/28/2014 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis Safety Bulletin discusses methods to improve the safe use of vasopressors. A specific patient safety incident is described and measures to enhance patient safety in this particular case are shared. A man in his 70s was transferred from a community hospital to the intensive care unit (ICU) of a tertiary care hospital with acute respiratory distress syndrome. He had been admitted to hospital 1 week earlier for community-acquired pneumonia. His condition had deteriorated despite treatment with broad-spectrum IV antibiotics. On arrival, the patient was receiving ventilation through an endotracheal tube. His respiratory rate was rapid, irregular, and poorly coordinated with the respirator. Deep sedation and neuromuscular blockade were required, but these measures resulted in profound hypotension. IV fluids and norepinephrine as continuous IV infusion were ordered by the intensivist. The norepinephrine was to be titrated to maintain mean arterial pressure (MAP) of at least 65 mm Hg. ICU staff were unable to achieve the target MAP despite increasing the doses of norepinephrine during the evening. The resident prescribed continuous IV infusions of vasopressin and epinephrine. Overnight, profound malperfusion occurred, along with multiorgan failure, despite the MAP being on target and even above. On arrival in the morning, the intensivist was surprised that he had not been notified of the situation sooner. The care team realized that they lacked a common understanding of the goals of vasopressor therapy. Continuing efforts to stabilize the patient’s condition were unsuccessful, and he died a few hours later from refractory shock. Recommendations to enhance the safety of vasopressor use are provided and focus on improving communication among team members (nurses, physicians, pharmacists), reassessing the indication for vasopressor therapy, and monitoring the dose. Given that vasopressors constitute a mainstay of therapy for many types of patients experiencing hypotension, given their potency and systemic effect profile, and given that patients who receive vasopressors are among the most vulnerable patients in the healthcare system, there is opportunity to enhance patient safety through the learning that has been shared in this bulletin and the recommendations presented. 7/7/2015 9:20:39 AM3
Overdose of intravenous paracetamol in infants and children10362NPSA04710/29/2010 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This signal address the risk of harm to infants and children from inadvertent overdose of intravenous paracetamol / acetaminophen and provides some actions to reduce risk. One patient safety incident is described whereby the healthcare provider intended to give a dose of paracetamol 10 mg/kg intravenously (IV) but gave 100 mg/kg instead. A doctor was summoned immediately and the overdose was treated. Treatment consisted of HDU (high dependency unit) level monitoring, acetylcysteine (Parvolex®) infusion and monitoring of blood tests. Contributing factors to paracetamol overdoses include: - lack of awareness amongst healthcare professionals of neonatal and paediatric drug dosage regimens; - patients receiving doses of paracetamol in both theatre and ward due to poor documentation; - human error relating to setting up infusion pumps to administer intravenous paracetamol (incorrect rate or incorrect/ no volume to be infused (VTBI)); - confusion between dosing regimens for oral and intravenous paracetamol with clinical staff believing they are interchangeable; - 10 times dose calculation errors in both the prescription and administration of intravenous paracetamol. Brief actions to reduce risk are provided and further guidance can be found on the MHRA Website. 7/7/2015 9:22:43 AM3
Quarterly Update on Wrong-Site Surgery: How to Do an Effective Time-Out in the Dark1077532306/1/2014 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 PM3
Distractions in the Operating Room1077932266/1/2014 6:00:00 AMSurgeryPennsylvania Patient Safety Authority (USA)This alert discusses the patient safety incidents that can occur in the operating room due to distractions and/or interruptions related to human communication, equipment such as surgical alarms or technology (e.g. phone calls, pagers). Distraction is a threat to patient safety in the operating room (OR). Analysis of events reported through the Pennsylvania Patient Safety Reporting System from January 2010 through May 2013 revealed 304 reports of events occurring in the OR in which distractions and/or interruptions were indicated as contributing factors. Attention is warranted to all events impacted by distraction in the OR regardless of frequency, due to their high potential to result in serious patient harm. Distraction is particularly detrimental to performance of complex tasks that require higher levels of cognitive processing, such as those frequently encountered in the OR. With regard to case-irrelevant communications (CICs), defined as communication not relevant to the surgical procedure in progress. Half of all CICs consisted of “small talk.” Although surgeons initiated and received the greatest number of CICs, visitors to the OR (defined as external staff not belonging to the OR team involved in the current surgical procedure) initiated CICs with the highest levels of observable distraction (i.e., causing team members to pause, disrupting workflow). Communications directed to nurses and anesthesia providers resulted in higher levels of distraction than communications directed to surgeons. Distraction from computers and personal electronic devices (PEDs) is also a growing concern for OR teams. The widespread use of computers in clinical settings, along with the recent rapid growth in the use of cell phones and smartphones, has contributed to a heightened focus on the potential for error and harm caused by distractions that result from the use of these devices, particularly within the OR environment. “Distracted doctoring” is a term coined by the media to describe this phenomenon. Distraction from smartphones and other mobile devices was identified as one of the top 10 health technology hazards for 2013 by ECRI Institute. The following are examples of Serious Events (i.e., events involving patient harm) reported and associated with distraction in the OR: —— Wrong-side surgery —— Wrong-site surgery —— Transfusion of the wrong blood to the wrong patient —— Failure to remove a piece of resected bowel, requiring a return to the OR —— Injection of a patient using an unlabeled syringe and needle previously used on another patient —— Failure to notice a significant loss of evoked potential from a patient’s arm during spinal surgery —— Inflation of a tourniquet applied to a patient’s leg for longer than intended, resulting in neurovascular changes Studies examining the impact of distraction in the OR setting, along with guidelines and tools developed by perioperative professional associations and patient safety agencies to limit and/or ameliorate the negative impact of distraction are discussed (e.g., application of the “sterile cockpit” concept from aviation, reducing distractions from technology and noise, use of surgical safety checklists and briefings, teamwork training). Engagement of surgeons and multidisciplinary teams is necessary to address the problem of distractions in the OR.7/22/2015 5:51:59 PM6
Peripheral Vascular Catheter–Related Infection: Dwelling on Dwell Time1078132243/1/2014 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 AM6
FALLS1079032171/1/2014 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 AM4
Correct Usage of Fume/Vapour Soaking Solutions1087731331/20/2014 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 AM8