Distractions in the Operating Room
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.
Training Suggested When Changing Brands of Enteral Feeding Tubes
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.