December 2012 Pennsylvania Patient Safety Advisory

Advisories & Events

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Pennsylvania Patient Safety Advisory

December 2012, Vol. 10, No. 4

201212

Reviews & Analyses

The Role of the Electronic Health Record in Patient Safety Events

The increased adoption of electronic health record (EHR) systems in the United States raises the risks of patient safety events related to health information technology. The Pennsylvania Patient Safety Authority analyzed reports of EHR-related events and identified several major themes.

Analysis of the Multiple Risks Involving the Use of IV FentaNYL

The Authority’s analysis of medication errors and adverse drug reactions involving intravenous (IV) fentaNYL revealed that the predominant medication error event types associated with IV fentaNYL were wrong-dose/overdosage events and wrong-drug events, which could lead to patient harm.

Surgical Fires: Trends Associated with Prevention Efforts

Seventy events of fires on the operating field were reported to the Authority in the seven years between 2004 and 2011. A coordinated approach to surgical fire prevention that includes risk assessment and adherence to best-practice recommendations is important to eliminate fire hazards.

Focus on Infection Control

Multifaceted Differences in Implementation of Practices for Prevention of Colorectal and Bariatric Surgical Site Infections

A collaborative improvement project to reduce surgical site infections (SSIs) in bariatric and colorectal surgical cases was initiated in December 2010 with the Pennsylvania National Surgical Quality Improvement Program. On-site interviews and assessments indicate that standardization and safety culture play significant roles in preventing SSIs.

From the Database

Potential Hazards of Clock Synchronization Errors

Clock synchronization issues can pose hazards to both patients and staff, and the increasing integration of medical devices and information systems suggests that there may be significant growth in the frequency and severity of this issue.

Updates

Quarterly Update on Wrong-Site Surgery: Facilities with Barriers to Best Practices May Experience More Wrong-Site Surgeries

When providers follow best practices to prevent wrong-site surgery, they can eliminate it. Results of following—or not following—best practices are illustrated by events reported the Pennsylvania Patient Safety Authority.

Other Patient Safety Information

Wrong-Site Surgery Protocol Followed

Event reports illustrate the importance of  multiple checks of the surgical consent, surgical markings, and communication among staff, patients, and family members.

Other Features

The Effects of Drug Shortages on Unsafe Injection Practices

Northeast Patient Safety Liaison, Jeffrey Bomboy, RN, BS, discusses infection outbreaks resulting from unsafe injection practices, the latter which are sometimes rationalized to conserve resources.

Letter to the Editor: Malignant Hyperthermia

A reader from a perioperative surgery center responds to a previously published strategy to prevent malignant hyperthermia.