Categories
Event Reporting Identifies Unanticipated Equipment Failure
Electronic Health Record
Medication
An organization reported several heparin infusion events over a year, which prompted several process changes in the electronic health record with the acknowledgement of orders, views within the medication administration record, and labeling of intravenous lines.
Uncovering a Health Record Error With a Nationwide Impact
Electronic Health Record
Medication
While rounding with an inpatient team, a clinical pharmacist identified that a patient’s medication list contained two medications to prevent stroke and heart attack, ticagrelor and atorvastatin, with no apparent indication.
System Malfunction Results in Incomplete Lab Orders
Electronic Health Record
Lab
When a nurse coordinator found out that lab orders could be faxed directly from the Epic electronic health record system, rather than needing to be printed and faxing a hard copy to lab facilities, she decided to test the functionality to make sure it worked correctly and accurately.
Updating Best Practices for Patient Diets
Electronic Health Record
Nutrition
A hospital’s Patient Safety Department noted safety concerns related to patients not receiving the correct diet. To understand what was happening, they identified and tracked 17 patients with incorrect diets.
Building a Safety Culture and Encouraging Reporting
Electronic Health Record
Equipment
Laboratory leadership embracing a culture of transparency and safety at their hospital—encouraging reporting through positive recognition of staff and continuous process improvement to mitigate operational risks—has increased reporting and resulted in positive changes to keep patients safe.
Catching Weight Errors in Real-Time
Electronic Health Record
Equipment
Following a significant harm event related to how patient weights were obtained at a hospital, the organization invested in replacing all hospital and clinic scales with metric-only scales; however, events continued to occur.
Patient History Alerts Keep Staff Informed and Prepared
Anesthesia
Electronic Health Record
Surgery
In some patients, anesthetics can cause a severe, sometimes lethal, reaction known as malignant hyperthermia (MH), with symptoms such as a dangerously high body temperature, rigid muscles or spasms, and a rapid heart rate.
Diabetes Task Force Improves Care
Electronic Health Record
Emergency Department
Nursing
At one facility, over a few months several incidents occurred involving patients in diabetic ketoacidosis (DKA), a life-threatening complication in which too much acid (ketones) builds up in the blood, in both the emergency department and acute care.
Engaging Staff in Solving Safety Issues
Electronic Health Record
Medication
After a health system experienced multiple events in which a patient received an insulin injection with another patient’s pen, with no improvements following root cause analysis and process changes, the safety team published an article in their patient safety newsletter soliciting ideas from staff.