Caring for Intoxicated Patients, Errors from Hospital and Health-System Outpatient Pharmacies, Retained Bioburden on Surgical Instruments, and more in the June 2017 Pennsylvania Patient Safety Advisory
Harrisburg, Pa., July 6, 2017 — Bullying or aggressive behaviors between healthcare providers can seriously impact safe patient care.
"Facility-reported events between healthcare providers in Pennsylvania included descriptions of verbal abuse, intimidating behaviors, and work interference," said Dr. Ellen S. Deutsch, medical director for the Authority.
In response to requests from Pennsylvania patient safety officers for resources to address workplace bullying, the Pennsylvania Patient Safety Authority analyzed such events reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS). Authority staff also developed a card-sized de-escalation tool that healthcare staff can keep with their name badges.
Authority staff reviewed events reported from July 1, 2014, through June 30, 2016, that described behaviors synonymous with bullying and identified 44 event reports that met specific criteria for workplace bullying between healthcare staff.
Workplace bullying can inhibit teamwork, block staff communication, and impede the implementation of new practices.
Of the 44 bullying events, most were categorized under event type other/miscellaneous (n = 25) followed by error related to a procedure, treatment, or test (n = 12). Of the events, the majority of descriptions involved verbal abuse (n = 34) and/or intimidating behaviors (n = 32).
"Forty-four reported bullying events between healthcare staff indicates that the existing dialogue about workplace bullying should continue," said Deutsch. "There are applicable strategies that facility leadership can put in place to empower employees through education, accountability, and enforcement."
In the Authority's June 2017 Advisory article, "Bullying in Healthcare: A Disruptive Force Linked to Compromised Patient Safety," healthcare staff will find information, insight, and risk reduction strategies to help combat bullying in the workplace. The Authority's accompanying Patient Safety Topic on bullying includes the aforementioned tool, Tackle Bullying with D.E.S.C., as well as other educational resources for healthcare facilities.
Download the full article.
Also published in this Advisory:
Frequent Monitoring and Behavioral Assessments: Keys to the Care of the Intoxicated Patient
Intoxicated patients and those under the influence of alcohol, regardless of care setting, pose unique challenges to healthcare providers. Assessment and management of these patients and behavioral assessment are key elements to the care and prevention of harm of the intoxicated patient.
Errors Originating in Hospital and Health-System Outpatient Pharmacies
Although a majority of prescriptions dispensed daily in outpatient pharmacies will be correct, errors occur. Error reduction strategies can be implemented in multiple stages of the prescription-filling process including during triage and order entry, production, and point-of-sale.
Retained Bioburden On Surgical Instruments After Reprocessing: Are We Just Scraping the Surface?
The design of medical devices, equipment, and instruments can provide ideal spaces for bioburden accumulation and subsequent development of surface biofilms. A quality-improvement initiative in surgical instrument reprocessing may help to combat bioburden prevalence.
Radiology Contrast Concerns: Reports of Extravasation and Allergic Reactions
Contrast media is used as an advanced imaging technique to improve diagnosis and is generally safe and effective. However, knowledge of adverse reactions, prevention, preparation, and adequate response when a reaction occurs are essential to providing safe care to patients undergoing contrast-related studies.
The Authority has recently refreshed its website. For more information about the Authority, patient safety topics, Advisory articles, and safety tips for patients, please visit patientsafety.pa.gov.
The Authority's mission is to improve the quality of healthcare in Pennsylvania by collecting and analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration. Its vision is safe healthcare for all patients.