This monthly newsletter keeps you up to date about what’s happening at the Patient Safety Authority, Pennsylvania facilities, and in healthcare today. As we step into the new year, in this edition we provide our 2023 year in review, highlighting the information, tools, and resources we developed and shared to help you in your work and help keep patients safe.
Safety Alerts
Methylprednisolone and Patients With Hypersensitivity to Cow’s Milk Components
Milk isn’t just for breakfast: Some medications contain lactose, so be aware if a patient has a milk allergy. In a recent harm event, one patient with a known hypersensitivity to milk experienced an anaphylactic reaction after receiving an intravenous dose of methylprednisolone (drawn from 40 milligram vials), a steroid used to treat allergies and their effects, such as swelling, inflammation, and other conditions. Following the event, the facility reviewed the drug package insert, which included a contraindication and warning for patients with known or suspected hypersensitivity to cow’s milk or its components. Fortunately, events like this can be prevented.>
Serious Harm Associated With Failure to Adjust Clozapine Dosing
Clozapine can be an effective treatment for schizophrenia when other antipsychotic medicines don’t work however, it is considered a last-line therapy, as it can also cause serious, potentially fatal, side effects. Pennsylvania healthcare facilities have reported severe cardiovascular effects in patients after clozapine therapy was interrupted and subsequently reinitiated at the same dose— including hypotension, bradycardia, and syncope. According to the manufacturer, if clozapine has been discontinued for two or more days, when therapy resumes the dosage should be adjusted to 12.5 milligrams once or twice daily. After reviewing event reports concerning cases in which clozapine doses were not titrated appropriately after an interruption in therapy, the Patient Safety Authority shared additional recommendations to help facilities protect patients from harm.
Writing Workshops
Quality improvement (QI) projects are an effective way for healthcare facilities to study a problem, implement changes, and examine their impact. Often the lessons learned, regardless of whether the initiative was ultimately successful or not, can help other facilities replicate the work to address similar problems or make other improvements on their own. This can only happen if the original project is shared, such as via a QI study in a journal with broad accessibility; however, many people don’t think to publish their results, or don’t know how to go about writing and submitting a formal manuscript. But it isn’t as hard as it might seem!
To help healthcare workers learn the basics of writing and submitting a QI study, the Patient Safety Authority (PSA) introduced the virtual Master Class Writing Workshop in Quality Improvement Studies with instructor Olivia Lounsbury, Quality and Safety Program coordinator, Johns Hopkins Children’s Center. Manuscripts produced from the 2023 fall and spring workshops have been appearing in Patient Safety, and the PSA is now accepting applications for the spring 2024 sessions
“Outside the Box” Webinar Series
Healthcare facilities may not appreciate just how many information sources are at their fingertips, especially some less obvious ones. In a five-part webinar series, “Outside the Box,” Patient Safety Authority experts shed light on a variety of tools that capture safety events happening in facilities and how to leverage them to identify potential risks. Monthly session topics from January to May included billing data and ICD-10 codes; patient reporting systems and complaints; audits, chart reviews, and trigger tools; medication technology, smart pumps, barcode medication administration, and automated dispensing cabinets; and media and publications.
Antibiotic Stewardship Webinar Series
Antibiotic resistance is an increasing problem in healthcare, especially in nursing homes where up to 75% of antibiotics are prescribed inappropriately. Contributing to this is pressure from residents and families, antiquated prescribing practices, and a “What could it hurt?” mentality. To help healthcare facilities develop robust antibiotic stewardship programs—whether building them from scratch or making quality improvements—Patient Safety Authority infection prevention advisors shared the latest information, resources, and best practices in a monthly, eight-part webinar series, “Antibiotic Stewardship.” From February to October, they presented on topics covering the types of antimicrobials and how to use them, mechanisms of antimicrobial resistance, antibiograms, clinical decision-making, and more.
Event Reporting Campaign
Reporting events that caused harm or could have caused harm to patients is not just a law in Pennsylvania, it’s also one of the best ways to improve patient safety. Event reports can be the first indication of underlying problems, regardless of whether harm occurs. They also are essential tools for triggering widespread change: Sharing details about events helps other healthcare facilities and staff avoid mistakes, learn from proven best practices, and better care for patients. With this powerful impact in mind, the Patient Safety Authority launched “Changemakers: Stories That Made a Difference,” a curated collection of stories about events that inspired people to improve care across their hospital, health system, or even nationwide.
IAPS 2023 Winners
Given the daily demands and challenges of healthcare, it’s important to take a moment to celebrate those who go above and beyond for their patients. Since the Patient Safety Authority introduced the I AM Patient Safety awards in 2013, this annual contest has recognized hundreds of teams and individuals for their advancements, outcomes, and commitment to patient safety. The awards are judged by a cross-section of national and regional healthcare executives; patient safety advocates; and government, university, and patient representatives. As judges review this year’s nominations from healthcare facilities throughout Pennsylvania and nationwide, read about the 2023 awardees and their exceptional efforts and impact.
Equipment Manuscript With Procurement Tool
To care for patients, healthcare staff rely on a host of medical equipment, supplies, and devices (ESD) every day. So, when a medical instrument fails or isn’t maintained or used correctly, the health and safety of patients can instead be compromised. A team of researchers reviewed 450 patient safety event reports related to ESD to identify the most common safety concerns and the human factors usability issues contributing to them. Data showed that the most frequently reported ESD-related safety issues were malfunction, sterilization, usability, and physically missing. Their detailed findings and insights, along with the patient safety procurement assessment tool based on their analysis, may help guide facilities in selecting ESD and making changes in their policies and procedures, and enhance training.
Emergence Delirium Webinar
Emergence delirium (ED) is a temporary but pot entially dangerous condition that may occur when a patient awakens after a procedure. In a webinar last April, complementing an article published in Patient Safety, staff at the VA Pittsburgh Healthcare System (VAPHS) shared how they implemented a perioperative intervention to reduce the risk of patient and staff harm. Participants included William Pileggi, MSN, CRNA, MAJ, USAR/AN (Ret.), a certified registered nurse anesthetist at VAPHS’s Department of Anesthesiology; Michael Boland, MSEd, training specialist for the Department of Veterans Affairs, VAPHS; and Matthew A. Taylor, PhD, a research scientist at the Patient Safety Authority, who described the process for screening patients, their medication strategy, and their methods to treat ED.
Patient Handbook
Healthcare can be confusing—and despite good intentions, patients and healthcare workers often seem to speak different languages. So, the Patient Safety Authority wrote a handbook to help everyone in the care team communicate better. The Patient’s Companion, designed by and for patients and clinicians, offers useful info and tips for healthcare encounters, such as how to handle a difficult diagnosis (and get a second opinion), how to access and update your electronic medical record, how to speak up for yourself and your loved ones during care, and many other topics. Read this pocket guide at no cost on your computer, tablet, or smartphone; print a copy to keep handy; and share the link with your friends, family, and colleagues.
Peer Review Week Lunch & Learn
Peer review is an important component of scholarly research, but many people—even authors just starting to publish—may not know what it is and what it means for them. For #PeerReviewWeek 2023, Patient Safety managing editor Caitlyn Allen, MPH, and author/editor/peer reviewer Zane Wolf, PhD, RN, professor of Nursing Programs and dean emerita at the School of Nursing and Health Sciences, La Salle University, provided an overview of what peer review is, how it works, and why is it so vital to scientific publishing.
