Patient Safety Authority

Technology in healthcare has expanded substantially over the last two decades. From electronic health records and barcode scanning to intravenous pump integration and best practice alerts, the work of healthcare providers is more automated now than ever before. But does this technology always make patient care safer? What happens when things don’t go as planned? The following are examples of reported events that illustrate errors based, at least in part, on the reliance of technology. Read and share: https://lnkd.in/ecgRUsaw

PATIENT SAFETY is currently open to research articles, quality improvement studies, focused reviews, patient perspectives, commentaries, data analyses, and other manuscripts that can help advance safety in healthcare. Learn more and submit your work at https://lnkd.in/eZMfKuAs. We look forward to reading it!

In December 2017, a “help-all” nurse assisting staff at a large academic medical center (AMC) couldn’t find the medication ordered for a patient in the automated dispensing cabinet, so she overrode the list of approved medications. This allowed her to select a different drug that began with the same letters, a high-alert medication demanding special handling—which resulted in a fatal medication error. Although such overrides are usually reserved for emergency situations, it was a common occurrence at this AMC. Following the serious event, the Centers for Medicare & Medicaid Services required the AMC to list actions to prevent this error from happening again. In assessing their corrective plan with an eye to the Institute for Safe Medication Practices’ hierarchy of effectiveness of risk-reduction strategies, Stolte et al. found that only 8% of the AMC’s strategies were high-leverage interventions such as forcing functions—in this case, removing the dangerous medication from the override list. Instead, most of their strategies were of low leverage (such as education, training, policy revisions, and suggestions to “be more careful”), which are not only easier to implement, but also less effective because they rely on inherently fallible humans to never make mistakes. Read and share: https://lnkd.in/eNV4hTGK

During a blood transfusion or within the 12 hours following the transfusion, patients sometimes experience respiratory problems or fluid in the lungs, a condition known as transfusion-associated circulatory overload (TACO). In April 2024, the Medicines and Healthcare products Regulatory Agency in the United Kingdom released a patient safety alert about an increasing trend of TACO-related deaths and major morbidity, which prompted the Patient Safety Authority (PSA) to examine event reports from Pennsylvania healthcare facilities. Researchers at PSA identified hundreds of reports of TACO events in recent years throughout the state, including some which resulted in serious patient harm or death. The PSA encourages the healthcare community to be aware of risk factors for TACO, its clinical presentation, and strategies to mitigate its risk. Read and share: https://lnkd.in/eVPSf6x9

To address prolonged hospitalization (more than seven days) of patients receiving intravenous antibiotics, Al Hada Armed Forces Hospital (AHAFH) turned to a well-established healthcare service that had not yet been widely adopted in Saudi Arabia: outpatient parenteral antimicrobial therapy (OPAT). First introduced 50 years ago in the United States, OPAT enables patients to receive care in their homes or in outpatient settings, reducing their hospital stays and increasing efficiency and comfort without affecting the quality of their care, as well as reducing costs and promoting antibiotic stewardship and the use of environmentally friendly oral antibiotics. Within just a year of implementing the OPAT program, from November 2020 to October 2021, the percentage of patients requiring intravenous antibiotics dropped from 23% to 12% and 673 patient days of hospitalization were eliminated. Read and share: https://lnkd.in/gabSPEcX

The drugs alteplase and tenecteplase are commonly referred to as “clot busters” because they dissolve clots that can lead to acute conditions such as ischemic stroke and heart attacks. Although they can be lifesaving, alteplase and tenecteplase are also considered high-alert medications which can cause serious harm to patients if used in error. They have been associated with several types of medication errors, due to their multidosing regimens and confusion around their naming and abbreviations, and because they are commonly administered in the same care area to treat similar patient populations. Patient Safety Authority researchers studied event reports from Pennsylvania facilities in which either alteplase or tenecteplase was prescribed to measure their frequency and delve into medication errors that involved the treatment of acute ischemic stroke. Their findings will help healthcare providers identify gaps in safety practices and develop strategies to minimize risks associated with these drugs. Read and share: https://lnkd.in/etgSbFrp

Third next available appointment (TNAA) is a measure of how long it takes for a patient to schedule a medical appointment, representing the third earliest slot after the first available one. The lower the TNAA the better; however, at the end of 2020, the Outpatient Department (OPD) at Al Hada Armed Forces Hospital (AHAFH), a tertiary hospital with 40 specialized services and specialties, noticed an increase in TNNA above their optimal target of 14 days or less—reaching as long as 18 days. A multidisciplinary team at AHAFH launched a quality improvement project to first monitor and understand patient flow and queuing, and the dynamics of clinic supply and demand, and then to develop strategies to reduce the TNAA to 10 days or less. Some of the challenges they identified included walk-in patients’ lack of referral criteria in specialties, and no-shows, which they addressed through interventions such as establishing a standardized referral system and introducing text message reminders before appointments. Their efforts reduced the average TNAA from 9.4 days before the intervention to an average of 5.6 days following the intervention. Read and share: https://lnkd.in/e-QeafeR

How many illnesses have childhood vaccinations prevented in the last 30 years? According to the Centers for Disease Control and Prevention (CDC), 508 million lifetime cases of illness. But that's not all: Since 1994, routine vaccines for children against diseases such as measles, mumps, and diphtheria have also prevented 32 million hospitalizations and more than a million deaths. The societal cost savings—direct costs, including medical costs, and indirect costs, for example, missed work—amount to $2.9 trillion. Read more in MedPage Today: https://lnkd.in/gmkftChT

Just published: The Patient Safety Authority established the annual I AM Patient Safety Achievement Awards to recognize Pennsylvania healthcare staff who have shown an extraordinary commitment to improving the well-being of patients. Even as we strive toward a goal of zero harm, it is also essential to recognize when things go right in hospitals and facilities. The IAPS contest is an opportunity to celebrate and share those stories, that they may inform and inspire others in their work. The 2024 IAPS awards were judged by patient safety advocates; government, university, and patient representatives; and healthcare executives, who carefully evaluated 130 nominations from 74 healthcare facilities for innovation, impact, sustainability, and scalability. In addition to the nine juried awards, PSA Executive Director Regina Hoffman, MBA, RN, selected a Choice Award winner for special recognition. Read and share stories of this year's winners in PATIENT SAFETY: https://lnkd.in/ePK5yKa6

👉Just published: Chlorhexidine gluconate (CHG) bathing has proven to reduce central line–associated bloodstream infections (CLABSI) in hospitalized patients. The aim of this study is to evaluate whether the implementation of a compliance monitoring process for CHG bathing and strict hand hygiene as part of the traditional CLABSI prevention bundle will reduce the overall hospital CLABSI standardized infection ratio (SIR). 👉Read it in PATIENT SAFETY: https://lnkd.in/euqpmJbX