Dislodged Gastrointestinal Tubes, Handoff Communications, and Retained Surgical Items, all in the March 2017 Pennsylvania Patient Safety Advisory
Harrisburg, Pa., Mar. 15, 2017 — Use of health information technology (HIT),
such as computerized prescriber order entry systems and pharmacy information
systems, can help prevent patient safety problems; however, if designed or
implemented poorly, HIT can have significant adverse consequences for patient
Between January 1 and June 30, 2016,
Pennsylvania healthcare facilities reported 889 medication-error events that
indicated HIT as a contributing factor. The most frequently reported errors
included dose omission, wrong dose or overdosage, and extra dose; the most
commonly reported systems involved were the computerized prescriber order entry
and the pharmacy systems.
“As more healthcare organizations
adopted EHRs [electronic health records] and such systems became increasingly
interoperable, the Authority observed an increase in reports of HIT-related
events, particularly in relationship to medication errors. In response, the
Authority implemented additional event reporting questions that would better
capture whether HIT was a contributing factor in reported events,” explained the
Authority’s executive director, Regina Hoffman.
In its last annual report, the Authority included quantitative data about
HIT-related events through 2015, and preliminary data suggested that the
predominant number of reports by event type was medication errors. In this
in-depth analysis of HIT-related medication errors released today, the Authority
characterized contributing factors of a recent report sample.
Authority analysts found that
HIT-related errors occurred during every step of the medication use process and
further, a majority of errors reached the patient. High-alert medications (i.e.,
medications that bear a heightened risk of patient harm if used in error) such
as opioids, insulin, and anticoagulants, comprised three of the top five drug
categories involved in most events.
“We can examine HIT system failures
for both human and system errors. Conducting a root-cause analysis when errors
occur, developing a strong culture of safety in which workers feel empowered to
report unsafe conditions, and routine HIT system surveillance are just a few
approaches to reducing HIT related medication errors. We can also learn from
systems that work well,” says Dr. Ellen Deutsch, medical director for the
For these and more risk reduction strategies,
see the full article.
Additional articles in this issue of the
Pennsylvania Patient Safety Advisory offer in-depth data analysis,
education, resources, guidance, and strategies about the following:
Dislodged Gastrointestinal Tubes: Preventing a Potentially Fatal Complication
: 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 and sepsis, other serious harm — including death — 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 in a patient’s body 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.
See the complete issue of the March 2017
Patient Safety Advisory.
About the Pennsylvania Patient Safety
Authority: The Authority was
established under Act 13 of 2002, the Medical Care Availability and Reduction of
Error (MCARE) Act, as an independent state agency. The Authority is charged with
taking steps to reduce and eliminate medical errors by identifying problems and
recommending solutions that promote patient safety. For more information about
the Authority, please visit our website at www.patientsafetyauthority.org or call 717-346-0469.