Our quarterly special editions feature articles, stories, interviews, and more from our journal, Patient Safety. In this issue you will read about the risk of using wheelchairs incorrectly, how to improve safety culture at your organization, ways to reduced delirium in hospitalized patients, why health information technology may increase the risk of duplicate medication orders, what patient safety looks like in Canada—and much more.
Caution: Wheelchair Misuse Can Cause Serious Harm
Wheelchairs are one of the most common assistive devices used in healthcare facilities and they seem simple to operate; however, using them incorrectly can cause a catastrophic injury to patients, visitors, volunteers, or staff.
The U.S. Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database, for reporting safety incidents related to medical devices, shows hundreds of wheelchair injuries since 2012. These involved various wheelchair types and included known risks like injuries from tipping the wheelchair over, but also lesser known, yet still catastrophic, risks like finger injuries. These injuries include cuts, loss of nails, broken bones, crushing injury, and loss of one or more fingers.
One way to prevent finger injuries to patients and staff is to read and follow the owner’s manual instructions on unfolding a wheelchair and where to place your hands when sitting, as well as recommendations for routine inspection and maintenance. Make sure that staff are trained to use a wheelchair before they use one to transport a patient. If wheelchairs are stored at the facility’s entrance and staff cannot supervise their use by patients or visitors, consider replacing folding wheelchairs with rigid frame wheelchairs that cannot be folded—or use an anti-fold device.
Watch the video:
https://youtu.be/od1ECM5pWA4
Perspectives — The Do’s and Don’ts of Taking Your Meds
“Can I use a teaspoon to measure my cough syrup?” “Is it ok to crush my pills?” “Are generic and brand name drugs really the same?”
People often have questions like these about their medications, but they’re too embarrassed to ask—or they don’t know whom to ask. In recognition of World Patient Safety Day 2022 on September 17, with the theme “Medication Without Harm,” Patient Safety collected questions about medication safety and consulted two experts to answer them: Michelle Bell, BSN, RN, director of Outreach & Education at the PSA and an Institute for Safe Medication Practices fellow, and Sharon Camperchioli, Pharm D, the medication safety officer at Children’s Hospital of Philadelphia.
In response to the question “How can I dispose of unused pills safely?” Bell responded, “Unused medication is a challenge for a lot of people. You might have a prescription that gets changed or you might need a different dose. Talk to your pharmacy. A lot of them have a prescription drop-off where you can take your unused medication, and they’ll dispose of it safely in a way that it’s not going to contaminate groundwater or get into the hands of a kid or a person who might use it inappropriately and then get sick or harmed from it.”
It’s Story Time: What We Can Learn From Malpractice
Malpractice claims often go one of two ways: they reach trial and become public knowledge or they’re settled out of court and are locked up in a nondisclosure clause, which prevents the public from not only learning about it, but also learning from it. Doctors Charles Pilcher and Mark Graber point out the missed opportunity of sharing these buried stories—anonymously—to improve patient safety and prevent these mistakes from happening again:
“Capturing the stories of patients who have been harmed by medical error is crucial. Stories are more effective teaching tools than academic papers and meta-analyses. Every great communicator understands that there is no better way to capture a reader’s attention than by starting off with a story.”
Burnt to a Crisp
“For the past 730 days I have consistently worked 80-plus hour weeks, 300 hours a month, six out of seven days of the week, multiple holidays, and even up to 28 days straight,” third-year surgical resident Mayher Profita writes.
That kind of a work schedule would take a terrible toll on anyone, but when a healthcare professional is suffering from burnout, they aren’t the only ones who can suffer. The health and safety of their patients is also at risk, and in Profita’s deeply personal account of a difficult time in her surgical residency, she reflects on how it impacted the way she responded to her responsibilities—and questioned whether she wanted to be a doctor at all. But she also shares how she came through the crisis and works to better care for herself, so she can better care for others.
“The grueling hours of residency had turned me into a person I never aspired to be. I was embarrassed by the fact that I, a person that prided themselves so much on mental toughness, had become burnt out. I wanted to go back to being the intern that ran to every page and treated every trauma alert and code blue as life or death. But I just couldn’t.”
The Future of Providing Safe Cancer Care
An estimated 1 in every 182 Americans will be diagnosed with cancer this year. Providing them safe care has inherent challenges, such as reaching an accurate diagnosis as quickly as possible, differentiating between disease progression and treatment side effects, and addressing broader systemic risks. Patient Safety managing editor Caitlyn Allen, sat down with Dr. Joseph O. Jacobson, oncologist and former chief quality officer of the Dana-Farber Cancer Institute, to discuss the evolution of oncology care and what the future may hold.
Jacobson says, “Cancer care today is much more of a team effort than it ever has been, and the patient must be a critical member of that team, actively involved in all care decisions. Treatments today are often highly complex and may be dispersed across a complex network of providers with more and more emphasis on outpatient care.” While this has made some things easier, such as making it more convenient for patients to receive chemotherapy and even bone marrow transplantation, it also makes it more challenging for the clinical team to coordinate complex care and ensure patient safety. He adds, “At the same time, it shifts more and more responsibility to the patient and her caregivers.”
Original Articles — Reducing Confusion About Delirium Helps Improve Outcomes
Each year more than 7 million hospitalized patients in the United States suffer from delirium, a state of confusion that comes on suddenly—yet it remains an underrecognized diagnosis from care teams. Symptoms can range from drowsiness (hypoactive delirium) to restlessness or agitation (hyperactive delirium), or a combination of these extremes. If delirium isn’t identified, an episode can last for hours or days, and it typically extends a hospital stay by 10 days; however, if the underlying cause is treated, it can be resolved more quickly
Anyone with a serious illness can develop delirium, even younger people, especially if they are in an intensive care unit or on mechanical ventilation—or undergoing treatments for cancer. To help increase early identification of delirium and reduce the safety risks, costs, and length of stay for patients, Cassandra Vonnes, DNP, from the Moffitt Cancer Center and Cindy Tofthagen, PhD, from the Mayo Clinic Florida implemented a quality improvement project around routine delirium screening by the nursing team. Their study provides an in-depth look at how facilities can come together to identify a problem and embrace lasting change that has a positive impact on staff and patients.
Double Trouble: Risks for Duplicate Medication Orders
Health information technology (health IT), such as electronic health records and computerized provider order entry, should improve workflows and make patients safer. But under some circumstances health IT can actually increase the risk of a patient mistakenly being prescribed multiple doses of the same or similar medication. To determine the causes of these types of errors and develop strategies to reduce them, researchers from MedStar Health Research Institute and the Patient Safety Authority analyzed 377 reports from 95 facilities in Pennsylvania.
They determined that 304 of these reports involved a duplicate medication order error, and more than one-third of those events resulted in the duplicate medication reaching the patient. Health IT issues contributed to 63 of the errors; other contributing factors included a prior dose or medication order not being discontinued (52) and gaps in care coordination (44).
To reduce the risk of duplicate medication orders, they recommend that facilities closely look at how their health IT systems are influencing care, as well as the frequency and usability of duplicate medication order alerts. Facilities also should consider whether clinical decision support tools could prevent these errors. They also emphasize that process improvement efforts should be multidisciplinary, including healthcare staff and experts in medication safety, health IT, and human factors.
Patient Safety Initiatives — 8 Lessons to Improve Culture of Safety
Change is hard, but making lasting changes to improve patient safety is even more difficult when healthcare workers are too afraid to speak up about problems. Kristin Neiswender and her team at Children’s Hospital of Philadelphia found a formula for success—which resulted in a 13% increase in staff rating scores for safety culture after two years—and they share how they implemented their novel, multifaceted just culture training program at the hospital, as well as the eight biggest lessons they learned along the way.
Lesson 1: Be thoughtful about who performs error follow-up. The simple step of removing direct supervisors from the incident review process made staff more open to discuss what went wrong. Lesson 2: Preparation matters. Those involved with reviewing the incident need to take their role and responsibility seriously and familiarize themselves with all the details of what happened and their organization’s related policies. Other takeaways underscore the importance of buy-in from leadership; sharing communication skills to help navigate challenging conversations and focus on the event, not the individual; and ongoing support and guidance to teams.
Five years after piloting this training, program leaders believe this model could be used across the organization for any type of error, and at any organization willing to commit time and resources to improving staff engagement and safety culture.
Patient Safety in Canada
We know healthcare in Canada differs from healthcare in the United States, but how does patient safety compare across the border? Ioana Popescu, director of Safety Strategies & Programs for Healthcare Excellence Canada, provides a comprehensive look at incident reporting and patient safety agencies and initiatives in her country.
She points out that no matter where you are, keeping patients safe includes learning from incidents so you can prevent them from recurring, and that requires data reporting and a strong culture of safety. While national incident reporting in Canada is limited to events involving medications, adverse drug reactions, and device failures, organizations such as the Canadian Institute for Health Information have helped bridge the gap. And patient groups, like Patients for Safety Canada, are ensuring that patients and their families are included in the conversation too.
To continue doing well, and do better, Popescu writes, “Patient safety is considered a global public health issue. Continued collaboration and learning and sharing with patients, families, and healthcare workers at all system levels—from local to global— have been and will continue to be essential.”
