Posted in Alerts, Preventable Errors, PSO Posted November 1, 2013
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.
Posted in Alerts, PSES, PSO, PSO case law, PSQIA Posted September 16, 2013
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
Posted in AHRQ, Alerts, Center Info, PSO Posted July 1, 2013
THE CENTER FOR PATIENT SAFETY’S LATEST ISSUE OF PSONEWS IS NOW AVAILABLE!
DOWNLOAD THE SPRING 2013 EDITION
OR VIEW IT ONLINE USING ISSUU
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:
Hospital & ASC PSO participation and implementation: Eunice Halverson, firstname.lastname@example.org
EMS PSO participation and implementation: Carol Hafley, email@example.com
LTC PSO participation and implementation: Kathy Wire, firstname.lastname@example.org
PSO data system, Survey on Patient Safety Culture, technical support: Alex Christgen, email@example.com
Posted in Alerts, Patient Safety Posted January 25, 2013
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.
Posted in Alerts, Falls, PSO Posted November 28, 2012
PSO Alert: The Center for Patient Safety is issuing an alert to all healthcare providers that may currently be using Ambien as a sleep aid for their patients. This includes but is not limited to hospitals, long term care, and nursing home affiliates.
The Mayo Clinic announced last week in “Health Day News” that a study involving 16,000 inpatients showed the fall rate for those taking Ambien as a sleep aid quadrupled, compared with patients not taking the drug.
Read the full PSO Alert.
Posted in Alerts, HAI Posted October 15, 2012
Meningitis from steroid injection medication continues to be a concern with 205 cases in 14 states, resulting in 15 deaths thus far. The medications were distributed to 23 states. The CDC provides the details and the latest information: http://www.cdc.gov/HAI/outbreaks/meningitis.html
“Multistate Fungal Meningitis Outbreak Investigation.” Centers for Disease Control and Prevention; dated 15 Oct, 2012. Web. http://www.cdc.gov/HAI/outbreaks/meningitis.html
The Joint Commission has issued a new sentinel event alert: Safe Use of Opioids in Hospitals. Although hospital patients may need the strong pain relief that only opioids can provide, a Sentinel Event Alert issued yesterday by The Joint Commission urges hospitals to take specific steps to prevent serious complications or even deaths from opioid use. MORE
Posted in Alerts, Patient Safety Posted September 2, 2011
The FDA has initiated the recall of all lots of Povidone Iodine Swabsticks, Povidone Iodine Prep Solutions, Povidone Iodine Scrub Solutions, and Povidone Iodine Prep Gel. To determine if you are using any of these items and information on return arrangements, check the full press release.