Pennsylvania Patient Safety Advisory
Aligning the Lines: An Analysis of IV Line Errors
Analysis of intravenous (IV) line events reported to the Pennsylvania Patient Safety Authority revealed that three errors were responsible for nearly 50% of the events: rate of infusion mix-up or line mix-up, IV lines not attached to patients, and errors associated with piggyback infusions. Several risk reduction strategies focused on these errors are discussed.
The Use of Patient Sitters to Reduce Falls: Best Practices
Based on data from 75 hospitals participating in the Pennsylvania Hospital Engagement Network Falls Reduction and Prevention Collaboration, a higher percentage of assisted falls and a lower rate of falls with harm may be associated with the use of sitters. Authority analysts identify specific sitter program design elements that have the potential to reduce rates of falls with harm.
Peripheral Vascular Catheter–Related Infection: Dwelling on Dwell Time
Pennsylvania data indicates that patients are at risk for peripheral vascular catheter (PVC)–related bacteremia after a PVC is in place for more than 72 hours. Waiting for a clinical indication of infection to re-site a PVC may lead to prolonged dwell times, and re-siting at 72 hours may reduce infection risk.
Quarterly Update on Wrong-Site Surgery: Queries and Responses
Ten wrong-site procedures were reported in Pennsylvania operating suites for the quarter of October through December 2013. Near-miss reports continue to demonstrate both areas of continued weakness and the effectiveness of the evidence-based best practices to prevent wrong-site surgery.
Commitment to Patient Safety Recognized in Pennsylvania
Executive Director Michael Doering discusses the Pennsylvania Patient Safety Authority’s inaugural “I Am Patient Safety” poster contest, in which the Authority recognized individuals and groups within Pennsylvania healthcare facilities who made a personal commitment to patient safety.