​Establishing standardized policies and procedures, including equipment checks and bedside signage indicating that the patient has a tracheostomy or a laryngectomy, as well as staff training on these policies and basic tracheostomy care, can help reduce the chance of airway-related complications and help both patients and staff breathe easier.

Serious medication errors can be devastating for patients and their loved ones, but fortunately they are both preventable and uncommon. In 2020, only 0.4% (166 of 46,568) of medication errors reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) were considered a serious event. According to PA-PSRS, 250 serious medication error events occurred in the emergency department (ED) from 2011– 20, and understanding how and why they happened can help prevent them from happening again.

Authors Elizabeth Kukielka and Rebecca Jones analyzed these events with a focus on the medications involved, when the error occurred, and the type of error. The data showed that more medication errors happened on the weekend versus Monday through Thursday and in the evening rather than the morning. Most of them occurred at the prescribing and administration stages of the medication-use process, and the most common errors were wrong dose and wrong type. The medications most frequently involved included epinephrine, opioid analgesics, and insulin.

Forewarned is forearmed—knowing this data and the wealth of information about ED medication errors presented in this study offers the opportunity to prevent them. Some safety strategies to consider: stock epinephrine autoinjectors, use computerized physician order entry with integrated clinical decision support, and add an emergency medicine pharmacist (EMP) to your emergency medicine team or expand existing EMP services. As this is the first study to consider the timing of serious medication errors in the ED, reduced staff overnight and a greater patient volume from Friday through Sunday also may be worth looking at as contributing factors. 

Although some may presume that patients relying on a tracheostomy tube to breathe have a “safe” airway with a lower risk of complications, researchers from the University of Pennsylvania Health System (Penn) determined that more than 20% of the highest-acuity emergency airway calls at the Hospital of the University of Pennsylvania involved patients with tracheostomies. This patient population has unique needs and health risks, requiring specialized training, care, and equipment— which is especially critical in emergency situations. Considering the combined 550 tracheostomy procedures performed each year at Penn facilities and the daily census of inpatients with trach tubes (5%–6%), the Penn airway safety committee turned their focus to addressing tracheostomy-related challenges throughout the healthcare system.

Their efforts revealed that a broad, multidisciplinary, and interprofessional approach is required to improve the quality and safety of tracheostomy care. Some of their recommendations include providing extensive education and training in tracheostomy assessment and interventions to the airway rapid response team, introducing airway safety grand rounds, conducting simulation activities, and tracheostomy safety nets.

Facilities interested in replicating and advancing their work can read about the approaches and results of their quality improvement initiative and seek further resources from the UK National Tracheostomy Safety Project and the Global Tracheostomy Collaborative, of which Penn is a part.

Have you implemented a successful quality improvement (QI) project that you know could benefit others? Many people want to share the results of their QI projects but keep putting it off, don’t think they have the time to write it up and submit it for publication—or don’t have any idea of where to start. If this sounds like you or someone you know, here’s a step-by-step guide that can help get your work into other people’s hands, where it can do even more good.

Writing a formal paper might seem overwhelming at first, but just like writing a college essay, it can become more manageable by organizing your information and breaking it down into smaller sections: the introduction with a problem description, rationale, and specific aims; methods, which include context, details about the intervention, and the study and measurements of the intervention; results and analysis; summary and interpretation; limitations; and a conclusion restating the impact and relevance of the intervention and suggesting next steps.

The author of this succinct and actionable guide, Patient Safety Movement Foundation programs manager Olivia Lounsbury, reassures all who might follow it that “the academic publication of your QI project could be much simpler than you previously imagined.”

 

​I AM Patient Safety is the Patient Safety Authority’s annual contest celebrating the things that go right each day to make patients safer. Judges selected individuals and teams from healthcare facilities throughout Pennsylvania and nationwide to receive awards in 10 categories: Safety Story, Transparency and Safety in Healthcare, Individual Impact, Improving Diagnosis, Physician Offices, Ambulatory Surgical Facility, Sepsis, Long-Term Care Facility, Time-Outs, and Nationwide Warriors. In addition to these winners and a special award chosen by PSA Executive Director Regina Hoffman, two runners-up in each general category are also being recognized for their commitment to patient safety.

Wrong-site surgery (WSS)—in which a surgical procedure is performed on the wrong side of the body, the wrong location, or on the wrong patient, or an incorrect procedure is performed—is considered a “never” event, meaning it should never happen. Yet, it does. In fact, from January 1, 2015, to December 31, 2019, 368 WSS events were reported from 178 healthcare facilities in the Pennsylvania Patient Safety Reporting System. Bob Yonash, senior patient safety liaison at the Patient Safety Authority (PSA), explains why.

“Based on my experience, the answer is multifaceted. In speaking with staff members in facilities throughout [Pennsylvania], including medical, nursing, and ancillary staff, there is no one answer. The [operating room] suite is notoriously busy, but I am told that this has been the ‘norm’ for many years. One theme though that I as an observer have come to realize is that all involved need to work as a team. From the patient requiring the surgical procedure to the surgeon who is ultimately responsible for their care and the many dedicated staff members in between.”

The good news is that WSS can be prevented by involving the patient and/or their family in verifying information about the procedure they need before and during the operation, using multiple pieces of information to confirm the procedure, and using surgical site marks to prepare for the procedure, and with a final time-out to check that the correct site is designated and the correct procedure is performed on the correct patient. The PSA released formal recommendations that expand on current guidelines to ensure correct site surgery on March 19, 2022.

 

Whether to become a nurse, therapist, pharmacist, or physician, students dedicate upwards of 15 years learning their profession, with countless hours spent studying topics like anatomy, pharmacology, and chemistry. But what about empathy?

Jefferson University created the Health Mentors Program to teach future caregivers what it’s like to experience the other side of healthcare. Health mentors—dedicated volunteers with chronic conditions such as diabetes, visual impairment, or limited mobility—meet regularly with teams of students to help them learn everything about medicine not found in a textbook. Patient Safety Managing Editor Caitlyn Allen sat down with program directors Drs. Anne Bradley Mitchell and Nethra Ankam, and faculty support Dr. Brooke Salzman to learn more.

“We’re so used to that biomedical model where students come with a desire to fix things,” Salzman said. “The Health Mentors Program forces the students to step back and be present with their health mentor and learn how to listen more empathically and not to jump into that fix-it mode. Listening is much more effective than making assumptions.”​