Guidance for Reducing Errors Associated with Prescribing Practices, Eye Surgeries, and Blood Transfusions Included in September’s 2016 Pennsylvania Patient Safety Advisory
Harrisburg, Pa., Sept. 22, 2016 — Despite the prevalence of sepsis and its serious consequences, awareness remains low, and sepsis is frequently under-diagnosed early on, when it is still potentially reversible.
Between April 1, 2014, and March 31, 2016, long-term care facilities in Pennsylvania reported 486 potential occurrences of sepsis to the Pennsylvania Patient Safety Authority, 17 of which were potential sepsis-related fatalities.
These events signify a patient safety concern for Pennsylvania’s long-term care facilities, particularly because adults 65 years or older are five times more likely to have sepsis than younger adults. As September is Sepsis Awareness Month, facilities may be able to avail extra attention to this important issue.
“Sepsis can have devastating consequences, so increasing education and awareness for both patients and clinicians is important,” said Ellen S. Deutsch, MD, MS, FACS, FAAP, medical director for the Authority.
“There are serious health consequences related to a sepsis diagnosis, even for survivors. Sepsis can often be successfully treated, but early diagnosis is key; this is especially true for older adult who are disproportionately at risk,” added Deutsch.
Authority infection prevention analysts note that sepsis as a life-threatening organ dysfunction, most often originating from an infection in the lungs, urinary tract, abdomen, or a surgical site. Long-term effects include sepsis induced inflammation, immunosuppression, functional disability, and cognitive impairment.
Using a sepsis screening tool and holding simulation sessions involving such a tool to identify sepsis early may help to optimize safety in the long-term care population. Further, incorporating a sepsis screening tool into the electronic health record can potentially aid with early identification.
“Early recognition is important, but so is treatment, which consists of at least antibiotics and fluids; possibly pressor support,” concluded Deutsch.
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Additional articles in this issue of the Pennsylvania Patient Safety Advisory offer in-depth data analysis, education, resources, guidance, and strategies about the following:
Prescribing Errors that Cause Harm
: Errors that occur in the prescribing phase of the medication use process are less likely to reach the patient due to the opportunity to intercept them. However, some errors do make their way through the entire process and cause harm. This article includes an evaluation tool to help organizations test their systems in order to better understand their ability to detect unsafe orders and their management of high severity alerts. Also included in this article are a self-assessment questions to help clinicians identify the most common prescribing errors, predict what types of errors may be intercepted by computerized prescribing orders, and to identify and assess risk reduction strategies to help prevent prescribing errors. See the prescribing errors toolkit
Process Assessment is Key to Prevention of Certain Ophthalmology Events
: Cataract removal and intraocular lens insertion is one of the most common surgeries performed in the United States. Events have steadily increased in Pennsylvania, and there is the opportunity to evaluate processes to prevent the potential for these events. Active participation by engaged staff in the execution of the Universal Protocol and use of an ophthalmology-specific perioperative checklist remain the recommended best practices.
Blood Transfusion Events—Lessons Learned from a Complex Process
: Although not all transfusion-related events are caused by errors, this complex process has many critical decision points at which errors can occur. Advances in donor screening, improved testing of the blood supply, emerging technology such as barcoding, and improvements in transfusion medicine practices have been found to increase the safety of blood transfusion.
See the complete issue of the September 2016 Pennsylvania 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.