Scabies, Health Literacy, and Innovation also Featured in the June 2016 Pennsylvania Patient Safety Advisory
Harrisburg, PA: An average of nearly two newborn misidentification events occur daily in Pennsylvania, according to estimates from the Pennsylvania Patient Safety Authority.
“Unique characteristics of the newborn population pose challenges for accurate and consistent patient identification,” said, Ellen S. Deutsch, MD, MS, FACS, FAAP, medical director for the Authority. “Hospitalized newborns often share similar birth dates and medical record numbers and, with multiple births, even share surnames.”
Authority analysts noted limited literature available specific to identification errors in newborns at a population level; however, analysts found 1,234 newborn identification events reported to the Authority (occurring from January 2014 through December 2015).
The majority of reported events involved procedure errors (e.g., mislabeled specimens), followed by general misidentification errors (e.g., missing or mismatched identification bands), medication events, and breast milk administration mishaps. Most events were reported as Incidents or “near misses” (events that do not harm the patient). Five events were reported as Serious Events (events that harm the patient), including events in which the wrong breast milk was given to the patient and a circumcision was performed without consent.
Analysts extrapolated contributing factors from the event reports. The resulting article provides risk reduction strategies, learning objectives, and self-assessment questions for hospital and birthing center professionals. “The information can be a start to ongoing discussions that purposefully address newborn identification errors in healthcare facilities,” said Deutsch. “Safety huddling, distinct naming systems, clinician awareness, and technology such as bar coding may help to decrease newborn identification errors in the future.”
Download full article here.
Additional articles in this issue of the Pennsylvania Patient Safety Advisory offer in-depth data analysis, education, resources, guidance, and strategies about the following:
As the Authority continues to provide quality analysis and education to healthcare professionals and empower patients and families through its Consumer Tips Guide for Patients and Their Families its new Executive Director, Regina Hoffman, plans to lead that charge through innovation. “We will use innovation to enhance our existing projects and services while pushing boundaries to help facilities develop unique insights into patient safety and discover untapped opportunities,” said Hoffman. From the timely and progressive patient safety information highlighted in this Pennsylvania Patient Safety Advisory, to the agency’s focus on healthcare facilities as essential partners in collaborative improvement, the Authority is determined to move the patient safety bar to the next tier across Pennsylvania.
Download the complete issue of the June 2016 Pennsylvania Patient Safety Advisory here.
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.
