Pennsylvania Patient Safety Authority Research Articles

Preventing Self-Harm in the Nonpsychiatric Health Care Setting.

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafety.pa.gov. For the original article discussed in this column or for other articles on patient safety, click on "Journal and Resources" and then "Advisory Archive" in the navigation menu.

Protecting Patients with Latex Allergies.

: The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafety.pa.gov. For the original article discussed in this column or for other articles on patient safety, click on "Advisories and Events" and then "Pennsylvania Patient Safety Advisory" in the top navigation menu.

Omission of High-Alert Medications: A Hidden Danger.

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

Health Care Worker Fatigue.

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

Fatigue as it Affects Nursing.

: Editor's note: From its first issue in 1900 through to the present day, AJN has unparalleled archives detailing nurses' work and lives over more than a century. These articles not only chronicle nursing's growth as a profession within the context of the events of the day, but they also reveal prevailing societal attitudes about women, health care, and human rights. Today's nursing school curricula rarely include nursing's history, but it's a history worth knowing. To this end, From the AJN Archives highlights articles selected to fit today's topics and times.In this month's article from the January 1935 issue, Lillian M. Gilbreth, a highly respected psychologist and industrial engineer, examines the problem of fatigue in nursing. A nonnurse expert, Gilbreth notes the negative effects of fatigue on skills, a problem "enormously more serious when the product of the work is human comfort and sometimes even human life, as it often is with the work of the nurse." In their article in this issue, "Health Care Worker Fatigue," Lea Anne Gardner and Deborah Dubeck of the Pennsylvania Patient Safety Authority share examples of fatigue-related adverse events and discuss the need for both personal and institutional fatigue risk management strategies.

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems.

In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems. We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database. Once each organization had its dataset of ventilator-related adverse events, reviewers read the narrative descriptions of each event and classified it according to the developed common taxonomy. A Pennsylvania Patient Safety Authority, FDA, and UHC search provided 252, 274, and 700 relevant reports, respectively. The 3 event types most commonly reported to the UHC and the Pennsylvania Patient Safety Authority's Patient Safety Reporting System databases were airway/breathing circuit issue, human factor issues, and ventilator malfunction events. The top 3 event types reported to the FDA were ventilator malfunction, power source issue, and alarm failure. Overall, we found that (1) through the development of a common taxonomy, adverse events from 3 reporting systems can be evaluated, (2) the types of events reported in each database were related to the purpose of the database and the source of the reports, resulting in significant differences in reported event categories across the 3 systems, and (3) a public-private collaboration for investigating ventilator-related adverse events under the P5S model is feasible.

Misplacements of Enteral Feeding Tubes Increase After Hospitals Switch Brands.

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events. Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

Preventing central line air embolism.

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

Saving Patient Ryan Can Advanced Electronic Medical Records Make Patient Care Safer?

Patient safety is one of the foremost problems in US healthcare, affecting hundreds of thousands of patients and costing tens of billions of dollars every year. Advanced electronic medical records (EMRs) are widely expected to improve patient safety, but the evidence of advanced EMRs' impact on patient safety is inconclusive. A key challenge to evaluating EMRs' impact on safety has been the lack of reliable and comprehensive data. We overcome this challenge by constructing a panel of Pennsylvania hospitals over 2005-2012 using data from several sources. In particular, we source confidential patient safety data from the Pennsylvania Patient Safety Authority (PSA). Since mid-2004, Pennsylvania state law has mandated that hospitals report a broad range of patient safety events to the PSA. Using a differences-in-differences identification strategy, we find that advanced EMRs lead to a 27 percent decline in patient safety events. This overall decline is driven by declines in several important subcategories — 30 percent decline in events due to medication errors and 25 percent decline in events due to complications. Our results hold against a number of robustness checks, including, but not limited to, falsification test with non-clinical IT and falsification test with a subcategory of events that is not expected to benefit from advanced EMRs. Overall, we provide evidence to policy makers, hospital administrators, and other stakeholders that hospitals' adoption of advanced EMRs improves patient safety.

Infection prevention practices in ambulatory surgery centers.

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, must file information on medical errors.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

Work-Arounds Slow Electronic Health Record Use

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, must file information on medical errors.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

Signals or Noise: Maximizing the Use of Clinical Alarm Systems for Patient Safety

Noisy environments, considered by some as synonymous with ED settings, have been clearly linked to distractions during critical tasks and medical error. 1 Welch J Alarm fatigue hazards: the sirens are calling. Patient Saf Qual Healthc. 2012; 9: 26-33 Google Scholar , 2 Pennsylvania Patient Safety Authority Supplement. Alarm interventions during medical telemetry monitoring: a failure mode and effects analysis. https://www.ecri.org/Documents/PA_PSRS/2008.03_Supplement.pdf Google Scholar , 3 Deardorff J Hospitals drowning in noise. Chicago Tribune. April 24, 2011; (Available at:) (Accessed October 23, 2013)http://articles.chicagotribune.com/2011-04-24/health/ct-met-hospital-noise-20110424_1_hospitals-neonatal-intensive-care-unit-noise Google Scholar Hospitals average around 72 dB of sound during the day and 60 dB at night, which is far in excess of the 40 dB set by the World Health Organization. 3 Deardorff J Hospitals drowning in noise. Chicago Tribune. April 24, 2011; (Available at:) (Accessed October 23, 2013)http://articles.chicagotribune.com/2011-04-24/health/ct-met-hospital-noise-20110424_1_hospitals-neonatal-intensive-care-unit-noise Google Scholar Even Florence Nightingale in 1860 in her Notes on Nursing warned against high levels of noise for safe patient care. 4 Nightingale F Notes on Nursing: What It Is and What It Is Not. http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html Google Scholar Although a variety of factors can contribute to unacceptable noise levels, alarms associated with various medical devices are a common denominator. Emergency departments are often a cacophony of sounds, with too many alarms from physiological monitors, ventilators, and smart infusion devices. The literature suggests that health care clinicians may be exposed to hundreds of alarms a day, 5 Cvach M Monitor alarm fatigue: an integrative review. Biomed Instrum Technol. 2012; 46: 268-277 Crossref PubMed Scopus (314) Google Scholar and within organizations, alarm signals are estimated to be in the thousands each day because of the wide availability of physiological devices available in each unit. 6 The Joint Commission Medical device alarm safety in hospitals. Sentinel Event Alert. 2013; (Available at:) (Accessed October 10, 2013): 60http://www.jointcommission.org/sea_issue_50/ Google Scholar Although there is no argument that alarm-equipped technology is essential to support safe care, it is also recognized that there are a number of patient safety challenges with the use of alarm systems, including the organization’s ability to address false alarms, nuisance alarms, alarm desensitization, and the real threat of alarm fatigue. 2 Pennsylvania Patient Safety Authority Supplement. Alarm interventions during medical telemetry monitoring: a failure mode and effects analysis. https://www.ecri.org/Documents/PA_PSRS/2008.03_Supplement.pdf Google Scholar , 5 Cvach M Monitor alarm fatigue: an integrative review. Biomed Instrum Technol. 2012; 46: 268-277 Crossref PubMed Scopus (314) Google Scholar , 6 The Joint Commission Medical device alarm safety in hospitals. Sentinel Event Alert. 2013; (Available at:) (Accessed October 10, 2013): 60http://www.jointcommission.org/sea_issue_50/ Google Scholar , 7 Lacker C Physiologic alarm management. Pa Patient Saf Advis. 2011; 8: 105-108 Google Scholar , 8 ACCE Healthcare Technology Foundation 2011 national clinical alarms survey. http://www.aami.org/htsi/alarms/pdfs/2011_HTFAlarmsSurveyFinal.pdf Google Scholar Susan F. Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP *ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.*ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention.

The use of collaboration to implement evidence-based safe practices.

The Pennsylvania Patient Safety Authority receives over 235,000 reports of medical error per year. Near miss and serious event reports of common and interesting problems are analysed to identify best practices for preventing harmful errors. Dissemination of this evidence-based information in the peer-reviewed Pennsylvania Patient Safety Advisory and presentations to medical staffs are not sufficient for adoption of best practices. Adoption of best practices has required working with institutions to identify local barriers to and incentives for adopting best practices and redesigning the delivery system to make desired behaviour easy and undesirable behaviour more difficult. Collaborations, where institutions can learn from the experiences of others, have show decreases in harmful events. The Pennsylvania Program to Prevent Wrong-Site Surgery is used as an example. Two collaborations to prevent wrong-site surgery have been completed, one with 30 institutions in eastern Pennsylvania and one with 19 in western Pennsylvania. The first collaboration achieved a 73% decrease in the rolling average of wrong-site events over 18 months. The second collaboration experienced no wrong-site operating room procedures over more than one year.Significance for public healthSince the Institute of Medicine’s To Err is Human identified medical errors as a major cause of death, the public has been interested in the recommendations for reporting of medical errors and implementing safe systems for the delivery of healthcare. The Commonwealth of Pennsylvania has followed those recommendations and found that an essential intermediate step between analysing reports and implementing safe systems is collaborative learning among healthcare institutions. The experience in Pennsylvania should be useful to other public organizations wishing to improve safety.

Caring for Class III Obese Patients

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, must file information on medical errors.Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

Violence Prevention Training for ED Staff

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, must file information on medical errors. Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

Effectiveness of a comprehensive hand hygiene program for reduction of infection rates in a long-term care facility

Alcohol-based hand rubs play a key role in reducing the transmission of pathogens in acute care settings, especially as part of a comprehensive hand hygiene program. However, their use in long-term care facilities (LTCFs) has been virtually unstudied. Infection data, including those meeting McGeer etal and the Pennsylvania Patient Safety Authority's surveillance definitions, for lower respiratory tract infections (LRTIs) and skin and soft-tissue infections (SSTIs), as well as hospitalization data were collected in a 174-bed LTCF for 22 months (May 2009 to February 2011). In March 2010, a comprehensive hand hygiene program including increased product availability, education for health care personnel (HCP) and residents, and an observation tool to monitor compliance, was implemented. Infection rates for LRTIs were reduced from 0.97 to 0.53 infections per 1,000 resident-days(P=.01) following the intervention, a statistically significant decline. Infection rates for SSTIs were reduced from 0.30 to 0.25 infections per 1,000 resident-days (P= .65). A 54% compliance rate was observed among HCP. This study demonstrates that the use of alcohol-based hand rubs, as part of a comprehensive hand hygiene program for HCP and residents, can decrease infection rates in LTCFs.

The Safe Use of Negative-Pressure Wound Therapy

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, must file information on medical errors. Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.

Reporting Practice Errors and Improving Patient Safety in Pennsylvania

This article discusses the creation and development of the Pennsylvania Patient Safety Authority, emphasizing the importance of reporting patient safety issues. Created as a solution to the twin problems of escalating medical malpractice insurance rates and the surprising number of patients harmed by medical errors, the Authority developed a Web-based system for reporting errors, an award-winning journal for analyzing errors and offering solutions, and educational programs and tools on patient safety. Because of the Authority's work, all Pennsylvania facilities can benefit from a single error in a single Pennsylvania institution.

Strategies for Decreasing Vascular Complications in Diagnostic Cardiac Catheterization Patients

Vascular complications are the most common type of complication after a cardiac catheterization. These include hematoma, pseudoaneurysm, arteriovenous fistula, peripheral artery occlusion and dissection, and retroperitoneal bleeding. The Pennsylvania Patient Safety Authority reports that nearly half the medical errors that occurred between June 2004 and December 2006 were cardiac catheterization complications, many of which were vascular related. The American College of Cardiology's National Cardiovascular Data Registry benchmark for vascular complications incidence is less than 1% for diagnostic catheterizations and less than 3% for percutaneous coronary intervention. The need to search for strategies to decrease vascular complication in diagnostic cardiac catheterization patients was a priority.

Fire in Labor and Delivery: Simulation Case Scenario

Fire in Labor and Delivery: Simulation Case Scenario