AUTHOR BIOGRAPHIES
Melanie Motts, MEd, RN, Patient Safety Authority
Melanie Motts (mmotts@pa.gov) is a senior patient safety liaison with the Patient Safety Authority for the Eastern region of Pennsylvania. Before joining the Authority in 2015 she worked in various leadership roles in outpatient and inpatient settings as a director of nursing, patient safety officer, manager, educator, and registered nurse. Motts is also a Certified Professional in Patient Safety (CPPS).
Lea Anne Gardner, PhD, RN, Patient Safety Authority
Lea Anne Gardner is a patient safety analyst with the Patient Safety Authority. She has more than 30 years of research experience in patient safety, performance improvement, cardiology, and behavioral health. She has served as a national director of nursing, quality improvement, and population health, and an administrative director of an institutional review board. Gardner is also a Certified Professional in Patient Safety (CPPS).
Abstract
As patient safety liaisons (PSLs), we are continually educating and collaborating with our Pennsylvania healthcare facilities. We often are asked questions about reportable events under the Medical Care Availability and Reduction of Error (MCARE) Act. One of the most common examples we discuss is cancellations and transfers out of an ambulatory surgical facility (ASF). The top three reasons for cancellations include preop instructions not followed, missed medical issues identified during preop screening, and no shows. The top three reasons for transfers include cardiac arrhythmias, aspiration, and hypertension. Interestingly, between discussions with facilities and review of event reports, new-onset atrial fibrillation (AF) has come up often as a common reason for cancellations or transfers out of the ASF setting, especially in gastrointestinal (GI) procedures. In fact, as PSLs, when educating ASFs on reportable events we often give the example of placing a patient on the cardiac monitor in preop and the patient is found to be in AF. In 2009, it was estimated that 13.1% of AF cases were undiagnosed, which may explain why patients are presenting with new-onset AF. People with AF are at an increased risk of complications (e.g., stroke); therefore, a cancellation or transfer may be necessary depending on the patient’s condition. These events are considered reportable to the Pennsylvania Patient Safety Reporting System (PA-PSRS) under MCARE.
