September 2013 Pennsylvania Patient Safety Advisory

Advisories & Events

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Pennsylvania Patient Safety Advisory

September 2013, Vol. 10, No. 3

201309

Reviews & Analyses

Oral Medications Inadvertently Given via the Intravenous Route

Errors involving intravenous administration of oral medications have been reported to the Pennsylvania Patient Safety Authority and have contributed to patient harm. Multiple error reduction strategies, such as dispensing oral medications in the most ready-to-use forms, can be used to minimize the occurrence of these events.

Spotlight on Electronic Health Record Errors: Errors Related to the Use of Default Values

Although the use of default values is intended to improve efficiency and standardization, events reported to the Authority indicate that patient harm can occur when default values are used inappropriately. Commonly reported events involved wrong times, outdated values, and system-entered information.

Class III Obese Patients: The Effect of Gait and Immobility on Patient Falls

Gait disturbances and immobility issues in class III obese patients place these patients at an increased risk for a fall. Some ways to mitigate this safety risk are through falls risk assessment and reassessment, as well as careful planning of class III obese patient policies and protocols.

Focus on Infection Prevention

Strategies to Fully Implement Infection Control Practices in Pennsylvania Ambulatory Surgical Facilities

Pennsylvania ambulatory surgical facilities (ASFs) requested education on infection control practices and on the Centers for Medicare and Medicaid Services’ Infection Control Surveyor Worksheet. Review of events reported by Pennsylvania ASFs to the Authority were combined with a survey of representatives of Pennsylvania ASFs at infection control workshops to focus on targeted strategies to fully implement infection control practices in ASFs.

Calculation of Outcome Rates That Diagnose Bedside Performance: Central-Line-Associated Bloodstream Infection

Aggregate rates of central-line-associated bloodstream infections (CLABSIs) can provide useful information, but differentiating between CLABSIs occurring during the insertion phase and those occurring during the maintenance phase of central venous catheter care can help organizations strategically allocate resources to improve infection rates.

Update

Quarterly Update on Wrong-Site Surgery: Work to Be Done

Facilities in the Pennsylvania Hospital Engagement Network (PA-HEN) collaboration were asked to take part in site visits by Authority analysts to evaluate compliance with the Authority’s goals and measurement standards associated with the 21 proposed recommendations to prevent wrong-site surgery. Results of these observations are presented.