Event Reporting Category

Categories

Not Settling for Empty Promises From Gas Cylinder Vendors

In a gastroenterology procedural center, a cart is used to integrate equipment for endoscopies and colonoscopies, including large (size E) carbon dioxide cylinders used for insufflation to reduce pain and discomfort during colonoscopies.

Taking Stock of Fluids to Find the Right Solution

Equipment

Medication

Nursing

After a hospital received several event reports of wrong and expired intravenous (IV) fluids caught before reaching patients, the medication safety officer investigated how these products were supplied. This institution purchases all their plain IV fluids from one manufacturer, so the products appear very similar.

Safety Team Goes to the Mat to Prevent Fall Injuries

Equipment

Falls

An integrated regional healthcare system initiated a new program to reduce both the incidence of patient falls and fall-related injuries in acute care facilities. As part of this program, fall mats were deployed in inpatient areas as an injury prevention tactic.

Holding the Line on Sterilization

Equipment

When central sterile processing staff identified a piece of ortho equipment as being difficult to sterilize, the manager stopped the line and immediately escalated the concern.

Allergy Awareness Leads to Systemwide Change in Anesthesia Practice

Equipment

Anesthesia

Surgery

A patient presented to the emergency department with complaints of abdominal pain. A thorough workup identified that the patient was suffering with a hiatal hernia; the patient was admitted to the hospital with a plan for operative repair.

Identifying a Supply Issue Affecting Patient Safety

Equipment

Nursing

Nutrition

A facility called the Patient Safety Authority with a concern regarding misplacements of nasogastric feeding tubes.

Reporting a Networkwide Supply Shortage

Equipment

Monitoring

Telemetry leads were on backorder, and replacement leads were being used instead.

Reporting a Problem Catches Unrecognized Systemwide Failure

Equipment

Monitoring

At around 10 p.m. on a Sunday, a registered nurse reported to her unit director that her telemetry pager was not receiving alarms for a patient with arrhythmias, although it had been working when she came on the night shift at 7 p.m

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.

Changing Procedures for Changing Trachs

Equipment

Respiratory

Three safety events involving bedside tracheostomy (trach) changes—downsizing and occasionally upsizing—occurred at a hospital in one year, one of which was self-reported by a respiratory therapist to the respiratory manager.

Facility Invests in Catching Weight Errors

Equipment

After a staff member at a large hospital identified weight errors in which patient weights were entered as pounds instead of kilograms and escalated the issue before the patients experienced significant harm, the hospital invested more than $500,000 to improve the patient weighing process and reduce the occurrence of weight errors to zero.