June 2014 Pennsylvania Patient Safety Advisory

Advisories & Events

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Pennsylvania Patient Safety Advisory

June 2014, Vol. 11 No. 2

201406

Reviews & Analyses

Distractions can be especially dangerous during performance of complex procedures that require high levels of cognitive processing, such as those performed in the operating room. Through teamwork training and the use of preoperative briefings and surgical checklists, among other practices, the occurrence and the effects of distractions may be minimized.

Healthcare Worker Fatigue: Current Strategies for Prevention

Reports to the Pennsylvania Patient Safety Authority have indicated that working extended shifts, multiple long shifts, or without a break or meal has led to adverse events related to fatigue. Although duty hour restrictions have been the focus of most fatigue risk management programs in healthcare, additional strategies are necessary to prevent these events.

An Analysis of Reported Adverse Drug Reactions

Over a 12-month period, Pennsylvania hospitals reported 4,875 events involving adverse drug reactions (ADRs) to the Authority, with nearly 30% of these involving contrast agents. Continually assessing the types of ADRs being reported, reviewing mitigation strategies for the involved medications, and updating protocols as necessary are strategies to reduce the incidence and severity of these events.

Falls Reduction and Prevention Update: Pennsylvania Hospitals Increase Implementation of Best Practices

Collaboration participants completing an annual self-assessment survey reported an increase in full implementation for 16 of 17 categories of falls prevention practices. Participants also conducting quarterly process measures audits achieved increased compliance with falls prevention practices and reductions in rates of falls with harm.

There was an increase in reports to the Authority of small-bore nasogastric feeding tube misplacements from January 2013 to October 2013 compared with the previous two years. Risk reduction strategies include staff education on feeding tube placement and verification, especially when new equipment is introduced.

Focus on Infection Prevention

Successful Strategies for Prevention of Bariatric and Colectomy Surgical Site Infections

Facilities participating in a joint collaboration of the Authority and the Pennsylvania National Surgical Quality Improvement Project achieved reductions in bariatric and colectomy surgical site infections. Additionally, the collaboration fostered success through development of a collaborative learning network and creation of comparison reports to measure progress.

Update

Quarterly Update on Wrong-Site Surgery: How to Do an Effective Time-Out in the Dark

There were 10 reports of wrong-site surgery in Pennsylvania operating rooms during the first quarter of 2014, the third consecutive quarter with 10 reports. In addition to discussing these event reports, Authority analysts describe safety processes for performing a time-out for a laser eye procedure.