2009 Patient Safety Authority Annual Report

Letter from the Board Chair

EXECUTIVE SUMMARY

THE AUTHORITY’S EDUCATION MISSION CONTINUES TO GROW

The Patient Safety Liaison Program

Enhanced Public Website

• Offers Pennsylvania-based healthcare information that is easier to read and find online with an enhanced search engine;
• Gives immediate access to the most recent information from the homepage featuring a spotlight section of “What’s New”;
• Allows users to browse-by-topic hundreds of Pennsylvania Patient Safety Advisory articles;
• Provides users with the means to distribute important Pennsylvania patient safety information through an “e-mail-to-a-friend” feature; and 
• Offers a vast collection of educational tools and resources for healthcare providers and community groups to improve patient safety in Pennsylvania healthcare facilities.

Patient Safety Training for Trustees Continued in 2009

Speakers’ Bureau and Information Booth

THE AUTHORITY INCREASES ITS ROLE IN FIGHTING HEALTHCARE-ASSOCIATED INFECTIONS (HAI)

Nursing Homes Begin Reporting HAI through the Authority’s Enhanced PA- PSRS System

ENGAGING PATIENTS AND CONSUMERS

Consumer Tips and Brochures

New Web Site Features Added for Patients and Consumers

HIGHLIGHTS OF DATA SUBMITTED TO THE PATIENT SAFETY AUTHORITY

• 528 hospitals, ASFs, abortion facilities and birthing centers submitted 226,670 reports of Serious Events and Incidents to the Authority, an increase of 6,796 reports from 2008. In 2009, the Authority received 18,889 reports per month on average, an increase of 3% from 2008.
• Approximately 96% of all reports submitted by these facilities in 2009 were Incidents, or did not cause harm to the patient. Approximately 4% of all reports were submitted as Serious Events, which indicates that the patient received some level of harm, ranging from minor, temporary harm to death.
• The number of Incident reports averaged 18,200 per month, an increase of 3.4% from 2008. Serious Event reports averaged 689 per month, a 4.3% decrease from the previous year. Part of the decrease can be traced to a certain event type (HAIs) some of which have previously been reported through PA-PSRS. Since February 2008, hospitals report all HAIs through the CDC's NHSN. However, taking into account the HAI reports from both years, Serious Events of other types increased 2.9% from 2008 to 2009.
  
• After approximately 1,150 nursing home representatives received training on reporting HAIs through PA-PSRS in 30 live sessions across Pennsylvania, 720 nursing homes began reporting HAIs to the Authority in June 2009. From July through December 2009, 16,729 HAI events were submitted to the Authority by nursing homes. The three most common infections reported are: Respiratory Tract Infections (RTI), Skin and Soft Tissue Infections (SSTI) and Gastrointestinal Infections (GI).
• In December 2009, the Authority surveyed Infection Prevention Designees (IPDs) at nursing homes. When asked how easy or difficult it was to submit a report through PA-PSRS, 94.7 % said it was very easy or somewhat easy to submit reports, 5 % were neutral and one respondent said it was somewhat difficult.
• Late in 2009, the Authority developed 13 analytical reporting tools for use within PA-PSRS by individual nursing homes. Using these tools, nursing homes are able to view and print facility- specific reports for all categories of infections, so they can identify trends and work towards investigating risk factors for reducing and ultimately eliminating HAIs.
• Reports from hospitals accounted for 90.9% of all reports submitted. However, ASF reports increased from 11.8 reports per facility in 2008 to 12.2. reports per facility in 2009.
• Statewide, the most frequently reported events in hospitals involved Errors related to Procedures/Treatments/Tests and Medication Errors (22%). Errors related to Procedures/Treatments/Test comprise 9% of reports involving harm and 6% of events contributing to or resulting in death. Medication errors comprise 4% of events involving harm and 1% of events contributing to or resulting in death.
• While Complications related to Procedures/Treatments/Tests comprise only 12% of reports overall in 2009, they comprise 42% of the reports of events involving harm and 59% of all reports of events resulting in or contributing to the patient’s death.
• Reports in perinatal patients (those aged 20 days or younger) increased 6.7%, from 4,107 reports in 2008 to 4,381 reports in 2009. Also, reports involving children and adolescents (those aged 21 years or younger) increased 16.8% in 2009.
• Reports in patients over age 65 also showed some changes in regard to Serious Events and Incidents. For example, elderly patients accounted for 64% of reports categorized as Falls in 2004 and 2005. This figure has declined steadily to 57.9% in 2009. Also, in 2009, reports with a primary categorization of Skin Integrity dropped from 73.1% occurring in patients over 65 in 2008 to 71.2% in 2009. Skin integrity reports include pressure sores, bruises and other skin- related conditions.
• In fulfilling its education mission in 2009, the Authority conducted a total of 16 on-site educational programs consisting of nine nursing home-related programs, four hospital/general healthcare programs and three ASF-related programs.
  
• In 2009 the Authority continued to develop its Patient Safety Liaison program, led by the Director of Educational Programs. At the time this annual report went to press, the PSL hiring process has been completed with five PSLs working in the PSL role and one scheduled to begin in May 2010. The PSLs will act as patient safety consultants to the hospitals, ASFs, birthing centers and certain abortion facilities that are required to report under the MCARE Act.
• In 2009 more than 200 PSOs attended educational programs developed by the Director of Educational Programs and PSLs. Many of these educational initiatives were spurred by feedback gathered from PSL visits with PSOs.
• The PSLs are also engaged in several collaborative programs within their regions that include topics such as mislabeling of blood specimens, wrong-site surgery, falls and central line- associated bloodstream infections (CLABSI).
• In a recent annual Authority survey, PSOs who responded to the survey reported making 633 changes in their facilities in 2009 as a result of specific Advisory articles produced by the Authority.
  

DATA COLLECTION AND ANALYSIS

THE REPORTING SYSTEM

Introduction

Interpreting PA-PSRS Data

• Data presented in this report include only reports of Serious Events and Incidents. While PA-PSRS also collects reports of Infrastructure Failures, these reports are submitted only to DOH. The Authority does not receive reports of Infrastructure Failures.
• Unless otherwise noted, data presented in this report are based on reports submitted through PA-PSRS between January 1, 2009, and December 31, 2009. Data from acute care facilities are presented in this section. Healthcare-associated infection data (HAI) from acute and long-term care facilities is presented on page 35 of this report.
• Unless specifically noted, numbers of reports in different categories are actual “raw numbers” and have not been adjusted for any facility- or patient-related factors that may influence differences in report volume among different facilities.
• The data are not adjusted to account for healthcare facility openings, closings or changes of ownership.

Definitions

• Serious Event—An adverse event resulting in patient harm. The legal definition, from Act 13, reads: “An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient. The term does not include an Incident.”
• Incident—A “near miss” in which the patient was not harmed. Act 13 defines this as: “An event, occurrence or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient. The term does not include a Serious Event.”
• Infrastructure Failure—A potential patient safety issue associated with the physical plant of a healthcare facility, the availability of clinical services or criminal activity. Act 13 defines this as: “An undesirable or unintended event, occurrence or situation involving the infrastructure of a medical facility or the discontinuation or significant disruption of a service which could seriously compromise patient safety.” Reports of Infrastructure Failures are not addressed in this report because these are submitted only to DOH.

• Hospital—The Health Care Facilities Act (35 P.S. §448.802a) defines a hospital as “an institution having an organized medical staff established for the purpose of providing to inpatients, by or under the supervision of physicians, diagnostic and therapeutic services for the care of persons who are injured, disabled, pregnant, diseased, sick or mentally ill, or rehabilitative services for the rehabilitation of persons who are injured, disabled, pregnant, diseased, sick or mentally ill. The term includes facilities for the diagnosis and treatment of disorders within the scope of specific medical specialties, but not facilities caring exclusively for the mentally ill.” For the purposes of this report, at the end of 2007, there were 243 Hospitals in the Commonwealth of Pennsylvania.
• Ambulatory Surgical Facility—The Health Care Facilities Act defines an ASF as “a facility or portion thereof not located upon the premises of a hospital which provides specialty or multispecialty outpatient surgical treatment. ASF does not include individual or group practice offices or private physicians or dentists, unless such offices have a distinct part used solely for outpatient treatment on a regular and organized basis. Outpatient surgical treatment means surgical treatment to patients who do not require hospitalization but who require constant medical supervision following the surgical procedure performed.” For the purposes of this report, at the end of 2007, there were 246 ASFs in the Commonwealth of Pennsylvania.
• Birthing Center—The Health Care Facilities Act defines a birthing center as “a facility not part of a hospital which provides maternity care to childbearing families not requiring hospitalization. A birthing center provides a home-like atmosphere for maternity care, including prenatal, labor, delivery, postpartum care related to medically uncomplicated pregnancies.” For the purposes of this report, at the end of 2009, there were five birthing centers in the Commonwealth of Pennsylvania.
• Abortion Facility—Act 30 of 2006 extended the reporting requirements in Act 13 to abortion facilities that perform more than 100 procedures per year. For the purposes of this report, at the end of 2009, there were eighteen qualifying abortion facilities in the Commonwealth of Pennsylvania.
• Nursing Home—Act 52 of 2007 revised Act 13 of 2002 (MCARE) to require nursing homes to report HAIs to the Authority. Reporting from these facilities began in June 2009. See page 40 for data received to date from nursing homes.

• Medical Error—This term is commonly used when discussing patient safety, but it is not defined in Act 13. The word “error” appears in the PA-PSRS system and in this report. For example, one category of reports discussed is “Medication Errors.” In PA-PSRS the word “error” is used in the sense intended by the Institute of Medicine Committee on Data Standards for Patient Safety, which defined an error as:
  
  
  The failure of a planned action to be completed as intended (i.e., error of execution), and the use of a wrong plan to achieve an aim (i.e., error of planning). It also includes failure of an unplanned action that should have been completed (omission).¹
  
  
  Within Act 13, the term medical error is used in the Declaration of Policy: “Every effort must be made to eliminate medical errors by identifying problems and implementing solutions that promote patient safety.” It is also used in defining the scope of Chapter 3, Patient Safety: “This chapter relates to the reduction of medical errors for the purpose of ensuring patient safety.”
  
  
  While PA-PSRS does include reports of events that result from errors, the program’s focus is on the broader scope of actual and potential adverse events-not only those that resulted from errors.
• Patient Safety Officer—Act 13 requires each healthcare facility to designate a single individual to serve as that facility’s Patient Safety Officer. Under Act 13, the Patient Safety Officer is responsible for submitting reports to the Patient Safety Authority. Act 13 also assigns other responsibilities to the Patient Safety Officer.
  

Standardization of Reporting Update

• They reported no Incidents in the year previous.
• They reported no Serious Events in the previous year.
• They reported less than 10% of the reporting volume for hospitals of similar size and type.

Report Volume

Reports by Month and Submission Type

Reports by Facility Type

Report Submission Trends

Reports by Event Type

• Medication Errors
• Adverse Drug Reactions (not a medication error)
• Equipment, Supplies, or Devices
• Falls
• Errors Related to Procedures, Treatments, or Tests
• Complications of Procedures, Treatments, or Tests
• Transfusions
• Skin Integrity
• Other / Miscellaneous

• Falls while Lying in Bed
• Falls while Ambulating
• Falls in the Hallways of the Facility
• Other Types of Falls

Reports by Region and Submission Type

Reports by Level of Patient Harm

• Unsafe Conditions—Circumstances that could lead to an adverse event (accounting for 10% of all reports)
• Event, No Harm—An event that either did not reach the patient or did reach the patient but did not cause harm (often called a “near miss,” accounting for 86% of all reports)
• Event, Harm—An event that reached the patient and caused temporary or permanent harm (3.5%)
• Event, Death—An event occurred that resulted in or contributed to death (0.1%)
  

Reports Involving the Patient’s Death

Patient Demographics

Patient Gender

Patient Age

Patients Most at Risk by Age

Elderly Patients

Perinatal Patients

Children and Adolescents

Reports by Location/Department (Hospitals Only)

• General Medical/Surgical Units
• General Medicine Ward
• Medical/Surgical/Oncology Unit
• Critical Care
• Emergency Department
• Burn Unit
• Medical/Surgical ICU
• Intermediate Unit
• Telemetry
• Cardiac Intermediate Unit
• Respiratory Intermediate Unit

​​HEALTHCARE ASSOCIATED INFECTIONS

Hospitals

Catheter-Associated Urinary Tract Infections (CAUTIs)

CAUTI National Comparison

Central Line-Associated Bloodstream Infections (CLABSI)

CLABSI National Comparison

Nursing Homes

• First, to implement the legal requirements of MCARE as modified by Act 52 of 2007, by establishing and maintaining the reporting system and publishing data to allow the assessment of HAI prevention efforts in this care setting.
• Second, to maintain the quality of the data through monthly validation.
• Third, to analyze the data to support Advisory articles, educational programs, and the Annual Report.
• Fourth, to use the data to identify facilities that are successful with their HAI prevention efforts and those that are unsuccessful in implementing best practices and to assist with methods of implementing improvement strategies.

• Nursing Unit
• Skilled Nursing/Short-Term Rehabilitation Unit
• Dementia Unit
• Ventilator Unit
• Mixed Unit

Analysis

• Respiratory Tract Infections (RTI): subcategory Lower Respiratory Tract Infections (LRTI) reporting the highest rates within the RTI category.
• Skin and Soft Tissue Infection (SSTI): subcategory Cellulitis reporting the highest rates within the SSTI category.
• Gastrointestinal Infection (GI): subcategory Clostridium difficile Infection reporting the highest rates within the GI category.

Respiratory Tract Infections

Urinary Tract Infections

Skin and Soft Tissue Infections

Gastrointestinal Infections

Other Infections

Facility Response to Infection

Organisms Identified in Laboratory Studies

Data Integrity and Validation

• Built-in logic which force answers to required questions.
• Validating entries against other information provided by the user, such as requiring the user to specify which infection criteria are met and giving them an error message if the set of criteria they chose is not valid.
• Reminder emails each month to prompt users to enter their utilization data (e.g., resident days and catheter days), which are required for calculating rates.

Nursing Home Analytical Reports

Nursing Home Feedback from the Annual Authority Survey

Pennsylvania Patient Safety Advisory Infection Articles

• MRSA surveillance cultures were obtained. Nares swabbing was conducted on every patient on admission, discharge, or transfer, followed by notification to the unit staff in a timely fashion of positive results.
• Prompt isolation precautions were instituted for staff and visitors. Contact precautions were initiated for colonized and infected patients.
• Weekly MRSA briefings were conducted, which included the executive team, unit staff (e.g., nursing environment management), and infection prevention and control, to share the unit’s successes and to identify resources and barriers needing administrative intervention.
• Aggressive hand hygiene protocols before and after patient contact were instituted. A hospital wide education campaign on hand hygiene was developed for the benefit of staff and visitors. Posters were visibly placed on each unit.
• Barriers to hand hygiene were removed. Alcohol handrub dispensers were placed at the entry/exit of patient rooms and other staff-identified locations.

• Elevation of the head of the bed (HOB) between 30 and 45 degrees
• Daily “sedation vacation” (i.e., lightening or weaning of sedation for the purpose of allowing patients to assist themselves to breathe and hence be ready for extubation as soon as possible)
• Daily assessment for readiness to extubate
• Peptic ulcer disease (PUD) prophylaxis
• Deep vein thrombosis (DVT) prophylaxis

• Elevating HOB 15 to 30 degrees for NICU patients
• Using neonatal oral hygiene care kits for patients of more than 25 weeks’ gestational age
• Implementing neonatal oral hygiene with sterile water for patients of less than 25 weeks’ gestational age
• Securing endotracheal tubes using standard procedures
• Discarding all tubing and circuits from standby ventilators
• Altering the frequency of ventilator circuit, tubing, and disposable oxygen equipment changes
• Adopting a standard for depth of suctioning and suction pressures
• Implementing a patient flow sheet to document completion of bundle elements
• Following implementation of the bundle, the VAP rate decreased by 60% to 1.5 per 1,000 ventilator-days in 2007 and 0.3 in 2008. The following further summarizes the results of implementation:

• The Compendium of Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitalswhich summarizes specific expert implementation and monitoring methods and addresses accountability as well as detailed process and outcome measures.
• The Guide to the Elimination of Cather-Associated Urinary Tract Infections (CAUTIs)published by the Association for Professionals in Infection Control, outlines evidence-based practice guidance to CAUTI prevention in acute and long-term care facilities, including antimicrobial stewardship, surveillance and data dissemination, as well as how to perform a CAUTI risk assessment.
  
• The Getting Started Kit: Prevent Catheter-Associated Urinary Tract Infections: How-to Guidefrom the Institute for Healthcare Improvement focuses on four components of patient care recommended for all patients and outlines specific methods to translate research into practice change at the bedside.
• Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008emphasizes specific recommendations for all aspects of CAUTI prevention and implementation initiatives, updates surveillance definitions, and lists clear indications for Foley catheter use.

Risk-Reduction Methods

• Standing orders for these vaccines which no longer require a physician’s signature
• Encouraging belief in the importance and effectiveness of vaccines
• Development of institutional policies related to assessment, consent, and orders
• Identification of a staff vaccine advocate.
  

​Ambulatory Surgery Facilities

HAI Advisory Panel

HAI Educational Programs
​​

Webinars

• Pennsylvania Nursing Home Reporting of Healthcare-Associated Infections under Act 52 of 2007
• Getting Past the Policy: Overcoming Barriers to Catheter Associated Urinary Tract (CAUTI) Prevention Practices. “Best practice” educational tools were provided as separate attachments for this Webinar
• Catheter Associated Urinary Tract CAUTI Prevention in Nursing home/Long-term care residents. Best practice tools were provided as separate attachments for this webinar.
• Beyond the Bundle – Reduce the risk of Central Line Associated Bloodstream Infection (CLABSI). Best practice tools were provided within the context of the presentation for this webinar.

On-Site Educational Presentations

Comprehensive Unit-Based Safety Program (CUSP) Initiative

• Learn how to apply the CUSP and CLABSI reduction tools.
• Receive tools for measuring CLABSI and safety culture in ICUs.
• Receive ongoing support through monthly calls.
• Have access to expert faculty for conference calls and face-to-face meetings.
• Receive a detailed ICU Operations Manual.

Help Desk Inquiries

2010 Plan For Infection Prevention Program

• Conduct a first look at nursing home data webinar
  
• Implement an automated alert tracker system with best practice guidance for nursing homes to notify them when unusual trends are detected
• Conduct ongoing in-depth data analysis
• Identify high and low performing facilities
• Visits to hospitals and nursing homes to identify best practices in high performing facilities and lack of practices in low performing facilities. We plan to conduct these visits by doing observations, reviewing records and utilizing additional methods that are being developed at the time of this report.
• Develop best practice tools based on facility visits
  
• Develop educational programs including webinars based on facility visits
• Develop Advisory articles based on findings
  

EDUCATION, OUTREACH AND COLLABORATION

THE PATIENT SAFETY LIAISON PROGRAM – ENGAGING IN CONVERSATION

PSL Mission: Educating Healthcare Facilities by Collaborating

A Complete PSL Program

Successes for the PSL Program

• The PSL program has fostered an increased awareness for the need to be proactive by instituting preventative strategies to reduce the likelihood of events as well as to report and learn from those unfortunate adverse events in order to generate a culture of safety. The PSLs have assisted facilities in looking at the redesign of systems and processes in order to enhance their patient safety programs.
  
• The PSLs have been able to foster the development of a culture of safety by emphasizing the benefits of the resources available through the Authority’s website, such as the Advisory, consumer tips, and educational tool kits. Specific toolkit materials such as the wrong-site surgery error analysis form and the wrong-site surgery prevention monitoring tool are now being used by facilities to create safer practices.
• The PSLs have encouraged facilities to include patients as active participants on their healthcare team distributing consumer tips on a broad range of topics such as, but not limited to, fall prevention, medication safety, hand washing and preventing wrong-site surgery in order to further advance the PSL Program mission of reducing/eliminating medical errors through communication, education and collaboration.
• PSOs have utilized the information provided by PSLs to enhance their overall patient safety programs. As an example, several ASFs identified the need to address fall prevention during post procedure care. However, they did not have a formal fall prevention program in place that identified the “at risk” patient, nor the measures outlined to decrease the chance of such an event. But, after reviewing these fall events and providing necessary resources (sample outpatient fall prevention protocols), new strategies were implemented within these ASFs and fall reduction has been noted.
• PSLs recognize that patient safety officers have competing priorities and that they may not have the means and/or ability to access certain resources in a timely fashion. When product recalls occur, facilities are usually seeking out alternative products that will best meet their needs. However, an event occurred in 2009 whereby an alternative product (an infection prevention product for allergy ridden patients) was difficult to find. Through electronic messaging, requests for those with knowledge of an alternate product were sent out to a list serve of PSOs in Pennsylvania. Interestingly, others responded back that they were in need of the same information. In the end, there was one respondent who assisted the group by not only identifying the product, but providing the complete product information whereby each facility had additional information as they moved forward with alternative products. Feedback from those requesting the information was very positive and appreciative.
• Several times in the past year facilities have openly shared their forms, tools, protocols, etc. One such event that impacted many was the sharing of medication reconciliation practices in ASFs. This practice is somewhat new to this setting. In an effort to institute the best practice, facilities have worked with PSLs to find helpful resources and sample forms that are being utilized by other Pennsylvania medical facilities. Several ASFs have developed medication reconciliation practices and instituted forms after reviewing others’ sample policies and forms that were shared via the PSL.
• Another example of the PSL’s assistance resulting in changed practice was with a facility that had experienced wrong-site surgery. The PSL visited with the facility and made numerous educational tools available to them. The facility reviewed the provided tools and made process and policy changes due to the information provided to them from the PSL.

• Communication of information regarding alternative OR Prep Solutions
• Standardizing color-coded wrist banding
• Enhancement of reporting awareness (especially “near miss”)
• Adoption of recommended changes to fall prevention programs
• Enhancement of overall patient safety program
• Development of medication reconciliation forms via shared examples
• Advertisement of consumer tips to encourage patient involvement
• Incorporation of Pennsylvania Patient Safety Advisory articles in staff newsletters
• Utilization of Authority educational materials (e.g. FMEA) post educational sessions
• Implementation of (World Health Organization) WHO surgery checklist
• Implementation of infection reduction strategies
• Clarification of MCARE (Act 13 of 2002) reporting requirements
• Utilization of the Patient Safety Authority educational tool kits
• Implementation of medication dosing guidelines for special needs populations
• Participation in analysis and prevention strategies for wrong-site surgery events

PSL Program Obstacle

ADDITIONAL EDUCATIONAL PROGRAMS AND COLLABORATIVES

PassKey (Patient Safety Knowledge Exchange) - Keeping the Conversation Going

• PassKey Home Page
  This page gives a calendar of events for the Patient Safety Liaisons so PSOs can know what other regions are doing to improve patient safety across the state. Contact information for each PSL is also provided along with tabs that direct users to PSL Region information, the Knowledge Center, Collaboratives, search and site map tabs.
• Knowledge Center Page
  The knowledge center page contains a knowledge library where PSOs can share policies, procedures, failure mode and effects analysis (FMEA), and other valuable information. Also, located on this page is an area where PSOs can discuss patient safety topics with their peers.
• PSL Region Page
  This page explains the PSL program and shows a map of each PSL region. Contact information for each PSL is listed here as well.
• Collaboratives Page
  This page gives a calendar list of the collaboratives occurring throughout the PSL regions. This information will keep PSOs in the loop in regard to the latest research and preventative strategies being done by the Authority in partnership with healthcare facilities throughout Pennsylvania.
• Site Map Page
  This page at-a-glance gives the sites available in PassKey. The sites are hyperlinks so it allows easy access to each page with a simple click.

Mislabeled Specimen Collaborative

Wrong-Site Surgery Collaborative

Falls Collaborative

• Falls per 1,000 patient days, and
• Falls with harm per 100,000 patient days

CUSP/CLABSI Collaborative

Patient Safety Officer Basic Foundation Course I

Beyond the Basics Course II

MRSA Presentation

Patient Safety Training for Trustees

THE AUTHORITY’S ANNUAL SURVEY OF PATIENT SAFETY OFFICERS

• Their opinion of the quality of the Advisory.
  
• Their impression of the Authority’s web site since its redesign.
• Their use of the Patient Safety Liaisons program.

Pennsylvania Patient Safety Advisory

THE PATIENT SAFETY AUTHORITY STRIVES TO EDUCATE

• We had a pressure wound lab recently, where staff were educated on staging & measuring of wounds. The feedback was positive. (Pressure Ulcers: New Staging, Reporting, and Risk Reduction Strategies )
• Revised our surgical site marking to comply with recommendations. (Surgical Site Markers: Putting Your Mark on Patient Safety )
• Having weighing litters available in several departments and requiring an accurate patient weight for any weight based medication (Medication Errors: Significance of Accurate Patient Weights )
• Look at sleep apnea studies prior to surgery. New H&P forms developed. Review of pre- operative patients chart 72 hours prior to surgery. (Patient Screening and Assessment in Ambulatory Surgical Facilities )
• Increased hand washing, extended information to families and residents. Infection control information given throughout the facility to other departments (Successful Reduction of Healthcare-Associated MRSA Infection Rates )
• Developed and gave presentation to medical staff and other healthcare personnel on DNR orders and living wills using the Advisory as a reference. (Understanding Living Wills and DNR Orders)

WEB SITE REDESIGN

REPORTING SYSTEMS

REACTION TO PSL PROGRAM

SUMMARY

• Generating useful patient safety information.
• Providing material to be used in education.
• Spurring process assessment and improvement.

PATIENT SAFETY GUIDANCE BASED ON REPORT ANALYSIS AND RESEARCH

ERRORS IN RADIATION THERAPY

• Use computerized systems.
• Computerized record and verify (RV) systems are employed by most linear accelerators. RV systems are successful at reducing the number of misadministration errors while allowing for delivery of complex treatment plans. RV systems verify that treatment parameters entered are the same that are set to be delivered to a patient. If these parameters do not match, then the external beam is inhibited from firing.
• Use of computer-controlled delivery systems can lead to reduction of errors while allowing for more complex treatment plans, without increasing the time involved. Three aims of computer-controlled delivery systems are (1) make treatment delivery more efficient, (2) improve accuracy of treatment, and (3) make new and more complex treatment modalities possible.
• Double check before delivery radiation therapy.
• Perform independent checks of the therapy treatment plan.
• Ensure proper patient identification procedures are in place and strictly followed.
• Consider an in vivo dosimetry program for quality assessment of machine calibration, planning dosimetry and dose calculation, patient setup, and influence of beam modifying components.
  

MEDICATION ERRORS: SIGNIFICANCE OF ACCURATE PATIENT WEIGHTS

• Obtain the patient’s correct and current weight when he or she arrives at the facility. Avail admitting areas (e.g., ED) with necessary equipment to weigh all patients (e.g., floor scales to weight patients on stretchers). Establish procedures for regularly reweighing patient populations in which weight fluctuation is anticipated.
• Standardize measurement systems to kilograms throughout the facility.
• Address the following issues associated with weight documentation:
• Review all documentation entry locations (e.g., printed order forms, computerized order- entry systems, infusion pumps).
• Require entry in computer systems before processing pediatric patient orders.
• Make patient weight a required field in all computerized order-entry systems.
• Test alerts in order-entry systems associated with maximum and subtherapeutic medication doses.
• Include the date when documenting patient weight to prompt recognition of old weight information.
• In the facility’s medication-use policies, mandate that all weight-based medications are not prescribed, dispensed, or administered unless the patient’s weight is available and has been considered by all practitioners.
  

BEYOND THE COUNT: PREVENTING THE RETENTION OF FOREIGN OBJECTS

• Perform counts according to national standards and facility policy.
• Conduct wound exploration before closure and whenever a discrepancy occurs.
• Document the count outcome, items used for packing, and actions taken in response to a discrepancy.
• Collaboratively develop count policies and procedures to promote interdisciplinary and consistent application.
• Ensure policies and procedures are readily available.

• Conduct routine postoperative radiographs. Note that radiographs are likely to detect stainless steel items; however, radiographs are less sensitive in detecting sponges and needles, the latter because of size.
• Approach RFO prevention through multidisciplinary, multiphase means. For example, identify patterns of failure, then educate about the problem (e.g., daily reminders about counting techniques), and finally monitor and communicate good results (e.g., use posters to track days since last RFO event).
• Augment manual counts through assistive technology such as radio-frequency detectable sponge systems, radio-frequency identification-detectable sponge systems, and bar-coded sponge systems.
  

SAFETY IN THE MR ENVIRONMENT: FERROMAGNETIC PROJECTILE OBJECTS IN THE MRI SCANNER ROOM

PREVENTING MATERNAL AND NEONATAL HARM DURING VACUUM- ASSISTED VAGINAL DELIVERY

• Conducting comprehensive preoperative assessment of both the mother and fetus
• Obtaining informed consent;
• Correctly applying technical expertise related to the chosen device
• Maintaining situational awareness
• Performing targeted postoperative maternal and neonatal assessments
  

CONFUSION REGARDING CONCENTRATION OF TAMIFLU® ORAL SUSPENSION

• Alert healthcare practitioners to this risk. In the event of a shortage, communicate the shortage and mitigation strategies to prescribers.
• Communicate suspension doses in mg rather than by volume.
• Include the patient-specific dose with corresponding number of mL and the concentration of liquid provided on the pharmacy-generated label.
• As an alternative, Tamiflu capsules may be opened and the contents (i.e., 30 mg, 45 mg, 75 mg) mixed with sweetened liquids for single doses.
  

NEUROMUSCULAR BLOCKING AGENTS: REDUCING ASSOCIATED WRONG-DRUG ERRORS

• Unsafe storage (e.g., vials of NMBAs placed in adjacent or wrong storage areas)
• Similar product labeling and packaging (e.g., vials of NMBAs confused with look-alike vials of different products, such as heparin)
• Look-alike drug names (e.g., Nocuron^® ordered but Narcan^® administered)
• Unlabeled syringes (e.g., accidental administration of syringes containing NMBAs that were unlabeled or mislabeled)

DOES YOUR ADMISSION SCREENING ADEQUATELY PREDICT ASPIRATION RISK?

• Inappropriate nutrition delivered to patients (e.g., feeding nothing-by-mouth [NPO] patients)
• Miscommunication between healthcare providers and departments (e.g., failure to communicate NPO status)
• Medication-related issues (e.g., administration of unauthorized doses)
• Misplacement of tubing during insertion (e.g., gastrostomy tubes)

• Conduct a swallowing screening on each admission and, as indicated, a full swallowing assessment and/or evaluation.
• Full bedside swallowing assessment is typically conducted after the admission screening identifies the patient at high risk for aspiration; preliminary swallowing screening conducted during admission assessment can effectively determine whether additional swallowing assessment and/or evaluation is warranted.
• Preliminary bedside swallowing screening tools can be in checklist or algorithm formats. An example is the Massey bedside swallowing screen.
  
• Conduct radiologic swallowing assessment.
• The American College of Chest Physicians identifies a videofluoroscopic swallow evaluation as beneficial for patients at high risk for aspiration or silent aspiration.
• The fiberoptic endoscopic evaluation of swallowing is a comprehensive screening that includes observation of the anatomy involved with the orpharyngeal stage of swallowing, structures within the hypopharanx, and secretions; assessment of food and liquid swallowing function; and response to therapeutic maneuvers and interventions.
• Review the patient’s medications.
• Some medications exacerbate dysphagia and aspiration; certain side effects may predispose patients to exhibit aspiration symptoms.
• Besides prescriptions, review should also include over-the-counter drugs, supplements, and herbal formulations.
• Develop individualized treatment plan.
• An interdisciplinary treatment plan is developed following a bedside screening and radiologic assessment, so the patient can receive safe and adequate nutrition.
• Interventions for those patients with aspiration and silent aspiration may include exercises and therapy.
  

MEDICATION ERRORS IN LABOR AND DELIVERY: REDUCING MATERNAL AND FETAL HARM

• Dose-omission errors comprised 22.5% (587) of the events, of which 34.8% (204) were associated with antibiotics. Antibiotics are often used to prevent neonatal Group B Streptococcus infection.
• Wrong-drug errors comprised 10.7% (280) of the events, of which 25% (70) involved high-alert medications, mostly infusions.
• Wrong-dose/overdosage errors comprised 6.4% (n=166), of which 46.4% (77) involved high- alert medications.
• Wrong-rate errors comprised 2.2% (58) associated with intravenous infusions. More than 55% (32) involved high-alert medications. The top three drugs were oxytocin, hydrations, and magnesium sulfate.
  

• Standardization
• Establish standardized concentrations, dosing regimens, administration protocols and order sets for high-alert medication infusions.
• Specify protocols for bolus doses.
• Infusion pumps and administration sets
• Adopt policy stipulating that all IV medications are administered via infusion pump (e.g., smart pump).
• Use different pumps for epidural versus IV infusions; avoid duel-channel pumps for simultaneous administration of both types of drugs.
• Labeling
• Differentiate (e.g., use bold fonts) IV infusion bags of high-alert infusions.
• Label infusion pumps and nearby IV tubing according to the solution being infused.
• Verify infusions by tracing tubing from the bag, through the pump, to the patient.
• Label epidural bags, syringes, and pumps (i.e., “For Epidural Use Only”).
• Storage
• Store separately high-alert IV drug infusions, epidural infusions, and fluids
• Designate separate areas for different medications needed during different phases of the birthing process.
• Restrict access to unneeded medications.
• Never store look-alike products side by side.
• Verbal orders
• Reserve verbal orders for emergent situations or when prescriber is physically unable to write or transmit orders.
• Double checks
• Require independent double check (drug, concentration, infusion rate, pump settings, line attachmentsand patient) before administration of high-alert medications.
• Monitoring
• When infusing high-alert medications, monitor patients’ vitals, oxygen saturation, and level of consciousness, as well as fetal heart tones, maternal uterine activity, and other patient parameters.
• If mother or fetus status changes, check infusing solution against intended medication.
• When giving drug boluses, monitor the patient at the bedside.
• In the event of overdoses, establish rescue procedures, and ensure necessary medications are available in emergency supplies.
  

PATIENT SCREENING AND ASSESSMENT IN AMBULATORY SURGICAL FACILITIES

• Patient age greater than 85 years
• Cardiovascular disease
• Peripheral vascular disease
• Obesity
• Obstructive sleep apnea
• Hyperactive reactive airway disease
• End-stage renal disease
• Malignancy
• Positive HIV status
• Operating room time greater than one hour
• A requirement for general anesthesia

• Preoperative screening
• This screening can occur by means of a telephone call or during a preadmission interview and serves as the initial identification of issues that could cause intra- or postoperative problems.
• The Association of periOperative Registered Nurses (AORN) recommends that a registered nurse assess components that includes baseline physical condition; allergies; signs of abuse; cultural, emotional and socioeconomic status; pain; medication history; anesthetic history; preoperative test results; discharge planning; referrals; physical conditions that may require additional equipment/supplies; informed consent; care plan; and documentation/communication of all gathered information.
• Successful strategies engaged by Pennsylvania ASFs also include use of comprehensive admission packets with automated address of trigger responses, as well as a cultivated relationship with the patient’s primary care physician office.
• Preoperative nursing assessment
• This assessment, which AORN recommends to occur on the day of surgery, is an opportunity to verify existing information and obtain any missing or incomplete information.
• Components involved in this assessment include verifying patient identity; reviewing preadmission screening/assessment; assessing baseline physical status; assessing NPO (nothing by mouth) status; identifying any advance directives; identifying the procedure; verifying site, side or level of procedure; implementing prescribed surgical preparation; assessing for prosthetics or implants; evaluating postoperative transport and aftercare; obtaining contact information of proxy; and assessing patient’s understanding of the information and discharge planning.
• Preoperative anesthesia assessment
• This assessment identifies issues related to perioperative anesthesia management.
• ASA endorses preanesthesia care components that include preoperative instruction; evaluation and examination by an anesthesiologist; verification of information (if nonphysician personnel are involved); conduct of preoperative studies and consultation, as indicated; and discussion of the anesthesia plan with the patient.
• One Pennsylvania ASF approaches preanesthesia assessment with two goals: (1) assess whether the patient’s condition is optimal, and (2) determine whether the planned procedure and anesthesia are appropriate for the patient.
  

OTHER ITEMS

FEDERAL LEGISLATION

PATIENT SAFETY LEGISLATION

RECOMMENDATIONS FOR STATUTORY OR REGULATORY CHANGE

ANONYMOUS REPORTS

REFERRALS TO LICENSURE BOARDS

PATIENT SAFETY DISCOUNT PROGRAM

BOARD OF DIRECTORS AND PUBLIC MEETINGS

• January 27, 2009
• March 10, 2009
• April 28, 2009
• June 9, 2009
• July 28, 2009
• September 8, 2009
• October 27, 2009
• December 8, 2009

FISCAL STATEMENTS AND CONTRACTS

FUNDING RECEIVED FROM HOSPITALS, ASFS, BIRTHING CENTERS, AND ABORTION FACILITIES

Facility Assessments

FUNDING RECEIVED FROM NURSING HOMES

Nursing Home Assessments

ANNUAL EXPENDITURES

PATIENT SAFETY AUTHORITY CONTRACTS

PATIENT SAFETY AUTHORITY BALANCE SHEET