March 2017 Pennsylvania Patient Safety Advisory

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Pennsylvania Patient Safety Advisory

March 2017, Vol. 14, No. 1

201703

Reviews & Analyses

Medication Errors Attributed to Health Information Technology

Nearly 900 medication error reports listed health information technology (HIT) as a factor contributing to the event submitted to the Pennsylvania Patient Safety Authority. The most common HIT systems implicated in the events were the computerized prescriber order entry system, the pharmacy system, and the electronic medication administration record.

Dislodged Gastrointestinal Tubes: Prevention, Recognition, and Treatment

Hospitals can decrease the risk for gastrointestinal tube complications by implementing best practices and risk reduction strategies to confirm proper positioning of gastrostomy tubes and to prevent, recognize, and manage dislodgement. Aside from peritonitis, sepsis, and death, other serious harm can result from even minor changes in gastrostomy tube position.

Handoff Communications: A Systems Approach

Handoffs are an integral part of care coordination and the delivery of safe patient care. Using handoff processes that incorporate critical thinking and reasoning skills to address patient needs and providing handoff training and education are strategies to improve patient handoff communications.

Retained Surgical Items: Events and Guidelines Revisited

Surgical items such as sponges, sharps, and instruments may be retained during surgery and can lead to serious patient harm. Detecting and reporting retained surgical items may help to determine patterns and root causes using a definition decided upon by the healthcare facility.

Focus on Infection Prevention

Data Snapshot: Improving Influenza Vaccination Rates of Healthcare Personnel in Pennsylvania Long-Term Care Facilities

Influenza is a contagious respiratory illness that can cause mild to severe illness and can lead to death. Long-term care facilities can promote influenza vaccination each season by reducing barriers to healthcare personnel vaccination.

Other Features

The Authority Celebrates Pennsylvania Healthcare Providers for Outstanding Patient Safety Efforts

The Pennsylvania Patient Safety Authority’s annual I Am Patient Safety contest promotes individuals and groups within Pennsylvania’s healthcare facilities who have demonstrated an exceptional commitment to patient safety. The Authority congratulates the individuals recognized for their efforts to improve patient safety in Pennsylvania’s healthcare facilities, and applauds their commitment.

Data, Data Everywhere… Not Any Time to Think!

The challenge in managing the potential for data overload is to determine the ideal middle ground between excessive data and insufficient information and to arrange the relevant information in a manner that supports clinicians’ cognitive processes.

Saves, System Improvements, and Safety-II

This recurring feature highlights successes of healthcare workers in keeping patients safe; in this instance, an experienced nurse catching a near 10-fold overdose of medication.