December 2015 Pennsylvania Patient Safety Advisory

Advisories & Events

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Pennsylvania Patient Safety Advisory

December 2015, Vol. 12, No. 4

201512

Reviews & Analyses

Addressing the Rise in Neonatal Abstinence Syndrome: A Multifaceted Approach

Helping newborns through withdrawal requires correct diagnosis and collaboration among the healthcare professionals who contribute to treatment, whether using pharmacologic or nonpharmacologic interventions. Families also play a key role in learning how to interact with their newborn, whose symptoms may include irritability, inconsolable crying, vomiting, and poor feeding.

Patient Flow in the Emergency Department: Phase III—after Disposition Decision through Departure

Analysts identified four key vulnerabilities in events occurring during phase III of the patient’s emergency department (ED) care: gaps in care unrecognized by ED personnel, delays, insufficient oversight, and lack of prompt transition. Care delivery and coordination may be enhanced through awareness of these vulnerabilities and implementation of risk reduction strategies and best practices in patient flow.

Medication Errors Involving Overrides of Healthcare Technology

The medication error events submitted to the Pennsylvania Patient Safety Authority involving the use of overrides when using technology reveal the complex nature and variety of factors that contribute to errors. Some of those factors were an extension of the unique challenges associated with the use of each type of technology; however, many of the factors were similar across all forms of technology.

Focus on Infection Prevention

Strategies to Turn the Tide against Inappropriate Antibiotic Utilization

The increasing incidence of multidrug-resistant organism infections has become a safety concern for patients in hospitals and long-term care facilities. Responsible antibiotic utilization and implementation of antibiotic stewardship programs are vital components of strategies to minimize multidrug resistance and Clostridium difficile infections.

Other Features

Prolonged Prone Positioning for Patients with Acute Respiratory Distress Syndrome

The Pennsylvania Patient Safety Authority received a request for guidelines and adverse event information about prolonged prone positioning for patients with acute respiratory distress syndrome.

Simulation Can Improve the Healthcare Systems We Work Within

Simulation is a powerful and adaptable tool that can be used to help us better understand, and improve, the complex sociotechnical systems that impact patient care.