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Bed Rail Entrapment11348PC0201/07/2001 6:00:00 AMBed Rail/RestraintNational Center for Patient Safety (Department of Veteran's Affairs - USA)"A patient’s head became wedged in the gap between the mattress and side rail of their bed, resulting in a partially obstructed airway. Guidelines for the dimensions and measurement procedures to evaluate the risk of entrapment related to hospital bed rails, bed frames and mattresses are included. This alert includes actions to reduce risk. "07/07/2015 8:42:04 AM
Balancing Family Bonding with Newborn Safety11073335001/09/2014 6:00:00 AMNeonatal/PaediatricPennsylvania Patient Safety Authority (USA)This alert discusses the patient safety incidents of newborn accidental injuries in the care of family members soon after a hospital birth. Hospitals face a challenge to support bonding of newborns with their families by encouraging breastfeeding, cuddling, holding, and touching while ensuring newborn safety. Analysis of reports submitted to the Pennsylvania Patient Safety Authority from July 2004 to 2013 showed there were 288 newborn events. Risk reduction strategies are shared in the alert and focus on implementing a falls prevention intervention, providing a safe sleeping environment, providing education for families on newborn safety that includes falls, and implementing a postfall huddle to examine why the fall occurred and what could be done to prevent future falls. Several of the strategies are included in the “Recommendations” section of this alert. 09/09/2015 11:16:13 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
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
Class III Obese Patients: The Effect of Gait and Immobility on Patient Falls10537310001/09/2013 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.27/07/2015 11:03:22 AM7
Aspirin for the Prophylaxis of Venous Thromboembolic Events – To Use or Not To Use10694323830/05/2014 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.22/07/2015 5:52:07 PM6
Quarterly Update on Wrong-Site Surgery: How to Do an Effective Time-Out in the Dark10703323001/06/2014 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.22/07/2015 5:52:07 PM3
Distractions in the Operating Room10707322601/06/2014 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.22/07/2015 5:51:59 PM3
FALLS10718321701/01/2014 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.27/07/2015 11:03:52 AM4
Overdose of intravenous paracetamol in infants and children10800NPSA04729/10/2010 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. 07/07/2015 9:22:43 AM3