June 2015 Pennsylvania Patient Safety Advisory

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Pennsylvania Patient Safety Advisory

June 2015, Vol. 12, No. 2

201506

Reviews & Analyses

Aligning Behavioral Health Management of Patient Aggression with State and National Initiatives

Operationalizing organizational changes to effect noncoercive patient care strategies requires a long-term commitment that starts with leadership. Many behavioral health facilities in Pennsylvania have aligned their approaches to noncoercive management of patient aggression with state and national initiatives, and analysts discuss two facilities’ strategies in particular.

Oral Anticoagulants: A Review of Common Errors and Risk Reduction Strategies

Pennsylvania healthcare facilities submitted 831 medication error reports associated with the oral anticoagulants warfarin, apixaban, dabigatran, and rivaroxaban to the Pennsylvania Patient Safety Authority from July 2013 through June 2014. The most commonly reported errors were drug omissions (32.5%), “other” errors (18.5%), and extra doses (11.7%).

Delivering the Right Diet to the Right Patient Every Time

A dietary error can occur at any point in the dietary process, from order entry through tray delivery. From January 2009 through June 2014, the type of dietary event most commonly reported to the Authority involved a patient receiving a tray with a food item to which he or she was allergic. Serious harm was reported in eight of these events.

Focus on Infection Prevention

Antibiotic Stewardship in Hospitals and Long-Term Care Facilities: Building an Effective Program

Inappropriate antibiotic use perpetuates and exacerbates antibiotic resistance. Antibiotic stewardship programs help to ensure optimal treatment for patients with infections and may enhance the length of time antibiotics in current use remain effective. Authority surveys of hospitals and long-term care facilities demonstrate opportunities for improvement in all facets of antibiotic stewardship.

Updates

Snapshot: Quarterly Update on Wrong-Site Surgery

There were 14 reports of wrong-site surgery in Pennsylvania operating rooms during the first quarter of 2015.

Other Features

“What Goes Wrong” (Safety-I) and “What Goes Right” (Safety-II)

Studying frequent events in which there was a “good catch,” in addition to events in which there were undesired outcomes, may add to our understanding of how to improve the safety of healthcare delivery.

Letter to the Editor: Working to Reduce Distractions in the Operating Room

Healthcare professionals in Australia share information on a project for reducing distractions in the operating room.

Self-Assessment: Wrong-Site Orthopedic Operations on the Extremities

These self-assessment questions may be useful for internal education and assessment regarding wrong-site operating room procedures on the extremities.