Nobody wants a medication error but often we don’t have a new strategy or method for prevention. Experts suggest that most errors are linked to a flaw in a system design or an unfortunate behavioral choice. Regardless, working towards prevention requires better processes as well as improving our safety behaviors. To learn more, check out this article by Kim D. McKenna MEd, RN, EMT-P, recently posted at emsreference.com.
The Agency for Healthcare Research and Quality has released the April WebM&M, morbidity & mortality rounds on the web. Spotlighted case is “Dissecting the Presentation“, with additional cases: “Transition to Nowhere” and “Fire in the Hole! – An OR Fire“.
Surgical checklists are also addressed this month with an interview with Lucian Leape,MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, and an interview with David Urbach, MD, MSc, Professor of Surgery and Health Policy, Management and Evaluation at the University of Toronto.
The Center for Patient Safety is issuing a Safety Alert based on industry data and recent findings from event data being submitted to the PSO. The following areas of concern have been reported to the PSO:
- A pediatric patient receives a higher than standard dose of Propofol and requires resuscitation.
- A battery fails on an insulin IV pump and goes unnoticed.
- Approximately one in every five reported PSO medication events involves a high alert medication such as anticoagulants (warfarin, heparin, Lovenox), Propofol, insulin, hypoglycemic agents, opioids and so forth. Events relate to prescribing, dispensing, administering and monitoring errors.
The Center for Patient Safety is issuing a Safety Watch based on industry data and recent findings from event data being submitted to the PSO. The following areas of concern have been reported to the PSO:
- Tube dislodgement during patient movement
- Patient aspiration
- Rapid Sequence Intubation
In Just CultureSM, we address two factors that often interact to undermine our efforts to provide safe and effective care. The first is severity bias. If an organization reacts to a harmful outcome by punishing the person involved, yet ignores the same behavior when the outcomes are good, that is severity bias. The article at the end of this link has a perfect example. Night nurses at a state group home frequently slept through their shifts. This was generally known. Yet, when a resident died because his nurse missed the two-hour check on his oxygen, the facility fired her. While her choice to sleep was a poor one, it was poor every night. And it was a poor choice for all the other staff members who did it. But only the one who got “caught” was punished.
When an organization tolerates these choices, it creates a culture that says the choices are OK—just don’t get caught. In the article, it seems that the home was able to fill hard shifts and pay staff less by allowing (or quietly ignoring) their choice to rest on shift. It normalizes deviance.
What message does your organization send to staff members by looking past (normalizing) choices that deviate from policy? And what further message does it send if it punishes only those individuals who are closest to a bad outcome?
The AHRQ is seeking case submissions for its WebM&M. Patient safety cases can be submitted anonymously by going to http://webmm.ahrq.gov/submitcase.aspx. About 1 in 3 cases submitted are accepted and organizations submitting cases receive a $300 honorarium. The Center encourages you to support the learning available through the AHRQ Web M&M and AHRQ Patient Network as well as the learning available to Center PSO participants by submitting patient safety details to enhance learning through PSO participation.
ISMP Medication Safety Alert for Hospitals, ASCs and anesthesia professionals! Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. ISMP is alerting hospitals, ambulatory surgical centers, and anesthesia professionals about the potential for dangerous mix-ups between two relatively new presentations of older medications, neostigmine injection and phenylephrine injection. Read more.
The Center for Patient Safety has released the 2014 PSO Report, containing findings reported by healthcare providers.
The data contained in the report is from the Center for Patient Safety’s PSO database. Licensed healthcare providers may participate in a PSO in order to share information, learn from the sharing, gain federal protection to support open reporting and ultimately reduce mistakes and patient harm. PSO participation is voluntary and organizations may choose to submit most or all adverse events or they may choose to submit only the more severe adverse events to share lessons learned. The event types and their severities, along with additional information, contained in the report are deidentified as required by the PSQIA.
The goal of the report is to present an overview of the findings within all of the events reported to the Center’s PSO, to learn how and why events are occurring, and inform providers and others about how to prevent future occurrences.
General CPS findings include: Read More