December 2017 Pennsylvania Patient Safety Advisory

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Pennsylvania Patient Safety Advisory

December 2017, Vol. 14, No. 4

201712

See the Action Agenda for this issue.

Reviews & Analyses

Near-Miss Event Analysis Enhances the Barcode Medication Administration Process

Pennsylvania healthcare facilities have increasingly reported events associated with barcode medication administration (BCMA). In collaboration with the Authority, a Pennsylvania health system used its “near misses” to improve its BCMA process.

Preparing for Unplanned Admissions to the NICU

Both premature and term infants have experienced unplanned admissions to the NICU. In Pennsylvania, the most frequently reported conditions were respiratory distress, metabolic issues, prematurity, neonatal abstinence syndrome, and infection.

Medication Errors in Outpatient Hematology and Oncology Clinics

Oncology care is provided in outpatient settings due to increased patient convenience and decreased cost; however, medication errors in this setting have not been fully explored.

Warming Blankets and Patient Harm

Hospitals seeking to prevent these adverse events can adopt risk reduction strategies consistent with perioperative guidelines for preventing and treating hypothermia and manufacturers' guidelines for device use and preventative maintenance.

From the Database

Data Snapshot: Complications Linked to Iatrogenic Enteral Feeding Tube Misplacements

Analysis of these misplacements found more than half led to complications, including death. Pneumothorax was the most common outcome; complications of other misplacements included coiling, perforation, and placement in the wrong portion of the GI tract.

Other Features

Saves, System Improvements, and Safety-II

This recurring feature highlights successes of healthcare workers in keeping patients safe; in this instance, the application of process standardization.

Patient Safety: No Harm, No Foul?

The unusual breadth of patient safety event report collection in Pennsylvania offers important and unique opportunities to inform our collaborative efforts to make healthcare safer.