WHAT YOU NEED TO KNOW

Our quarterly special editions feature articles, stories, interviews, and more from our journal, Patient Safety. In this newsletter you will read how artificial intelligence could benefit healthcare, best practices for visual display design, stories of patient safety heroes, and more.

Patient Safety Alert: 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 mg 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. One step that facilities can take is to check their formulations of methylprednisolone for the presence of lactose monohydrate; it’s important to check each vial size, as they may contain different components. It’s also important to review and update patients’ allergies, including food allergies, at every encounter and document the date and type of manifestation as appropriate.

Original Articles — Informing Visual Display Design of Electronic Health Records

Electronic health records (EHRs) are commonplace, but so are design flaws that make them harder to use and read—contributing to clinical staff burnout and diagnostic errors that may result in harm to patients. To help improve the way complex patient information is presented in EHRs, human factors researchers studied the visual display guidelines of industries that, like healthcare, are considered high-risk: automotive, aviation, and nuclear.

From hundreds of documents, they gleaned best practices that could be applied to EHRs and categorized them according to alphanumeric; color, brightness, contrast, and luminance; comprehension; design characteristics; symbols, pictograms, and icons; and tables, figures, charts, and lists. Healthcare facilities, EHR vendors, and policymakers can apply these recommendations to improve the usability, efficiency, and—most importantly—safety of EHR visual displays.

2022 in Patient Safety

In conjunction with the Patient Safety Authority’s 2022 annual report, we published two articles in Patient Safety analyzing 2022 data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), the nation’s largest event reporting database of its kind.

In “Patient Safety Trends in 2022,” PSA data analysts take a close look at the 256,679 incidents and serious events reported by acute care facilities last year, while “Long- Term Care Healthcare-Associated Infections in 2022” examines 20,216 HAI reports from long-term care facilities last year. They supplement the data overview in the annual report with a comprehensive review and analysis of events reported in 2022, as well as insights into patient safety in Pennsylvania and how we may continue to improve it together.