Safety Alert Issued: High Alert Medications

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PSOAlert!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.

Read More…

Safety Watch Issued: Cricothyrotomy

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Safety WatchThis Safety Watch is to advise you that having multiple different types of cricothyrotomy kits can lead to confusion during an airway emergency.  We believe standardizing your equipment including cricothyrotomy kits within an organization or within a region would help to reduce the likelihood of an adverse event.

Cricothyrotomy also commonly called a “cric” is an emergent procedure for establishing an immediate airway.  The procedure can be performed several ways with various commercially prepared kits or with specialty prepared equipment.  The skill requires the provider to access the cricothyroid membrane to establish an airway for oxygenation and ventilation.

Possible reasons for these events:

  • Access to different types of kits can lead to confusion during an airway emergency

View the full Safety Watch to see recommendations for mitigating risk.

EMS PSO Alert: Morphine vs Midazolam

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PSOAlert!The Center for Patient Safety has released a PSO alert regarding the potential for confusion when administering Midazolam or Morphine.

As a Patient Safety Organization (PSO), the Center for Patient Safety collects incident, near miss, and unsafe condition information on multiple types of healthcare related cases, including EMS medication events.

Recently, there has been a trend of medication errors pertaining to the administration of the incorrect medication involving Morphine and Midazolam.  Specifically, confusing the two medications and administering the wrong medication.

Possible reasons for the error:

  • Similar names of medication
  • Similar packaging or container
  • Similar route of delivery
  • Medications were locked together
  • No cross check process in place or time out taken before administration

Read the full alert and view recommendations and helpful resources.

Inaccurate Data Source for Surescripts Services Potentially Impacting Patient Safety

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National Alert Network Issues Alert on Surescripts “Medication History Acute” and “Medication History Ambulatory” services containing inaccurate information.

The National Alert Network has issued a new alert pertaining to the data source for Surescripts’ “Medication History Acute” and “Medication History Ambulatory” services potentially containing inaccurate information that could jeopardize patient safety. The Network indicates that the potential inaccuracy relates to the strength of a drug reported in the medication history drug description field, and results from missing special characters such as a decimal point, forward slash, or percentage in some records. The Alert also indicates that Surescripts has disconnected the data source from the services until corrected, and communicated the potential risk to all EHR vendors. The alert advises health care professionals to “question and confirm any medication dosages reported in electronic medication history information that appears inappropriate given the patient’s unique characteristics and current health status.” Health care providers are also encouraged to contact their EHR vendor to determine if the issue affects their systems.

ALERT ISSUED: Preventing Retained Surgical Items

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The Center for Patient Safety and The Joint Commission have released alerts regarding the preventing of retained surgical items.  The alerts reflect data the Center for Patient Safety (CPS) is seeing.

As a Patient Safety Organization (PSO), the Center for Patient Safety collects incident, near miss, and unsafe condition information on multiple types of healthcare related cases, including retained surgical items (RSI).  RSIs are unintentionally retained objects from an invasive procedure.

While RSI events do not occur often, they still happen.  In cases of RSIs, the item is often discovered and removed right away.  However, this requires additional surgical procedures, can cause the patient undue strain and may extend their recovery time.

PSO data reveals the most often reported retained items are sponges and guide wires, but other cases include broken surgical items like drill bits, and parts of instruments and devices.

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PSO ALERT! Need for Clear Policies and Educated Defense Counsel

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New Kentucky Appeals Court Decision Underscores the Need for Clear Policies and Educated Defense Counsel

(Mercy Health Partners-Lourdes, Inc. v. Kaltenback, No. 2013-CA-000053-OA, entered July 11, 2013)

Download a printable version

The Center’s participants have heard us preach about defining clear boundaries for their Patient Safety Evaluation Systems (PSES) and implementing clear PSES policies.  Courts will examine these policies closely in determining whether information generated as part of patient safety activities can be protected as Patient Safety Work Product (PSWP).  They will also examine the path of purported PSWP to see if the organization has followed its own policies for protected information. Read More

NOW AVAILABLE: Spring Edition of PSONews!

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The Spring 2013 PSONews edition includes articles on the AHA recommendation for hospitals to join PSOs now rather than wait for the January 1, 2015 requirement.  Timely articles also cover National Drug Shortages, the Center’s Annual PSO Day, the Survey on Patient Safety, and much more…

• It’s a New Day!
• Center Remains National Leader
• Good Catch!
• Annual PSO Day
• Medication Errors in EMS
• PSO Data Snapshot
• PSO Calendar and Tidbits

NOTE:  Some links within the newsletter are password protected for Center PSO participants-only.

QUESTIONS?  If you have questions about PSO services, please do not hesitate to contact any of our dedicated staff members, or if you have a specific healthcare field to address, contact a PSO team member below:

Becky Miller, MHA, CPHQ, FACHE, CPPS, Executive Director,
Eunice Halverson, MA, Patient Safety Specialist,
Kathy Wire, JD, MBA, CPHRM, Project Manager,
Alex Christgen, BS, Project/Operations Manager and Analyst,
Lee Varner, BS EMS, EMT-P, Project Manager, EMS Services,
Michael Handler, MD, MMM, FACPE, Medical Director
Amy Vogelsmeier, PhD, RN, GCNS-BC, Contractor


ALERT: Glacial Acetic Acid Solutions not recommended for patient care

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The National Alert Network (NAN) has released a warning regarding the potential for severe patient burns and scarring from “accidental application of ‘glacial’ acetic acid (less than or equal to 99.5%) to skin or mucous membranes instead of a much more diluted form.  Glacial acetic acid is the most concentrated form of acetic acid available.”  The article recommends replacing current stocks of glacial acetic acid with vinegar or a commercially available diluted acetic acid, educating staff about the differences between glacial acetic acid and diluted acetic acid, and put safety guards in place to restrict purchasing.  Read the full alert

The NAN bases alert information on errors reported to the National Medication Errors Reporting Program and is operated by the Institute for Safe Medication Practices.

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