December 2004 Pennsylvania Patient Safety Advisory

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Pennsylvania Patient Safety Advisory

December 2004, Vol. 1, No. 4

200412

Five years after the release of the seminal report, To Err is Human, and six months after the start of PA-PSRS, how are Pennsylvania facilities responding to patient safety?

The Role of Empowerment in Patient Safety

Procedures will only improve patient safety if team members feel empowered to act when they believe the procedures are not being followed.

Risk of Unnecessary Gall Bladder Surgery

Event reports discuss attempted cholecystectomy procedures in patients who had previously had their gall bladders removed; these previous procedures did not become known until the patients' surgeries were performed.

Snip-It Safety

Reported scissors-related injuries include superficial nicks, lacerations, and even a case of amputation of a finger tip; lessons learned focus on avoidance, assessment, use of blunt instruments, visibility, control, and positioning.

Follow-up on Previous Advisory Articles

Patient Safety Officers share feedback and follow-up on two topics of previous Advisory issues (i.e., insulin and tuberculin syringe confusion, time out processes).

Medications Contributing to Fall Risk

Approximately 21% of reports of patient falls indicate that the patient was receiving one or more drugs that can contribute to falls risk.

Medication Errors Linked to Drug Name Confusion

There are many strategies organizations can implement that may help prevent medication errors due to confusion between drug names.

Fetal Lacerations Associated with Cesarean Section

Several interventions may reduce the risk of fetal laceration associated with Cesarean section, including use of blunt instrumentation, moving the uterine wall away from the fetus before incision, and removing abdominal wall retractors before delivery.

Early Discharge from the ED

Event reports discuss patients who were discharged too soon after presenting to the emergency department with poisoning, perhaps due to cognitive bias on the part of clinicians.

A Rare but Potentially Fatal Complication of Colonoscopy

If a healthcare team has a high index of suspicion of splenic injury in patients who develop abdominal symptoms after colonoscopy, successful outcomes from this rare complication are more likely to occur.

Venous Air Emboli and Automatic Contrast Media Injectors

While most air emboli associated with the use of intravenous contrast media are asymptomatic, the literature includes numerous symptoms that indicate this complication.

A Word About Air Detection Devices

Air detection devices are not foolproof systems and cannot be relied upon solely to prevent air embolism associated with contrast media injectors.

Drug Name Suffix Confusion is a Common Source of Errors

There are many inconsistencies in the practice of adding suffixes or modifiers to medication names to maintain brand name awareness and signify different formulations.

Understanding the Benchmarking Process

To be effective, benchmarking must provide a systematic method of understanding the underlying process that determines an organization's performance.