Pennsylvania Patient Safety Research Articles

Slow Down: New-Onset Atrial Fibrillation Challenges for Ambulatory Surgical Facilities

As patient safety liaisons (PSLs), we are continually educating and collaborating with our Pennsylvania healthcare facilities. We often are asked questions about reportable events under the Medical Care Availability and Reduction of Error (MCARE) Act. One of the most common examples we discuss is cancellations and transfers out of an ambulatory surgical facility (ASF). The top three reasons for cancellations include preop instructions not followed, missed medical issues identified during preop screening, and no shows. The top three reasons for transfers include cardiac arrhythmias, aspiration, and hypertension. Interestingly, between discussions with facilities and review of event reports, new-onset atrial fibrillation (AF) has come up often as a common reason for cancellations or transfers out of the ASF setting, especially in gastrointestinal (GI) procedures. In fact, as PSLs, when educating ASFs on reportable events we often give the example of placing a patient on the cardiac monitor in preop and the patient is found to be in AF. In 2009, it was estimated that 13.1% of AF cases were undiagnosed,3 which may explain why patients are presenting with new-onset AF. People with AF are at an increased risk of complications (e.g., stroke);3,4 therefore, a cancellation or transfer may be necessary depending on the patient’s condition. These events are considered reportable to the Pennsylvania Patient Safety Reporting System (PA-PSRS) under MCARE.

The Safety of Benzodiazepines and Opioids in the Geriatric Population: An Analysis of Patient Safety Events Reported by Hospitals and Ambulatory Surgical Facilities

Benzodiazepines may increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in patients 65 years and older. The concomitant use of benzodiazepines and opioids may also be inappropriate for older adults due to the increased risk of overdose. We searched the Pennsylvania Patient Safety Reporting System (PA-PSRS) for reports of patient safety events related to the concomitant use of benzodiazepines and opioids in older adults in order to gain a better understanding of the potential risks of using these medications in combination. We identified 80 reports in which a patient may have experienced an adverse drug reaction (ADR) to the combined use of a benzodiazepine and an opioid pain medication. Reports were reviewed to determine the ADR(s) experienced by the patient. Changes in mental status were most common, occurring in more than two-thirds of reports (68.8%; 55 of 80), followed by respiratory reactions (51.3%; 41 of 80) and cardiovascular reactions (25.0%; 20 of 80). In over two-thirds of reports (70.0%; 56 of 80), the patient received a reversal agent, either flumazenil (10.7%; 6 of 56) or naloxone (35.7%; 20 of 56), or both (53.6%; 30 of 56). The inappropriate use of benzodiazepines and opioid pain medications in combination among patients 65 years and older is a growing problem, and an increased awareness may be the first step for providers to begin addressing it.

Urinary Tract Infections in Pennsylvania Long-Term Care Facilities

Urinary tract infections (UTIs) are common healthcare-associated infections (HAIs) in older adults that live in long-term care (LTC) facilities. A query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) found that symptomatic UTI (SUTI) and catheter-associated UTI (CAUTI) rates increased from 2016 and peaked in the second quarter of 2020. Although the number of urinary catheter days reported by LTC facilities has trended downward from 2016 to the beginning of 2020, the urinary catheter utilization rate increased slightly in the second quarter of 2020. We also examined various epidemiological factors. An average of 47.6% of SUTIs and 32.3% of CAUTIs were associated with E. coli from 2016 through 2020. However, the percentage of CAUTIs associated with E. coli decreased while the percentage of CAUTIs associated with organisms of the tribe Proteeae (Proteus, Providencia, and Morganella genera) increased from 2016 through 2020. Furthermore, the percentage of CAUTIs associated with carbapenem-resistant Enterobacterales (CRE) and organisms producing extended-spectrum beta-lactamases (ESBL) also increased, while the percentage of CAUTIs associated with vancomycin-resistant Enterococci (VRE) decreased from 2016 through 2020. An average of 38.5% of SUTIs and 41.5% of CAUTIs were reported to be treated with fluoroquinolones from 2016 through 2020. However, the percentage of both SUTIs and CAUTIs treated with fluoroquinolones decreased from 2016 through 2020, while an increasing percentage of both SUTIs and CAUTIs was reported to have been treated with cephalosporins and carbapenems from 2016 through 2020. Thus, to further promote resident safety, we use these epidemiological trends to better understand current risks for residents and to further guide development of best practices for prevention, identification, and treatment of UTIs as well as to further advance antibiotic stewardship practices.

Perioperative Delirium/Agitation Associated With the Use of Anesthetics and/or Adjunct Agents: A Study of Patient Behaviors, Injuries, and Interventions to Mitigate Risk

Anesthetics and adjunct agents have a long history of being associated with patients engaging in delirious or agitated behavior in a perioperative setting. Prior to this study, few have explored the topic with a focus on safety for both the patient and staff. We explored the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for event reports to identify bouts of delirium/ agitation associated with anesthetics and/or adjunct agents that occurred during the pre-, intra-, or postoperative period. We identified 97 event reports from 63 healthcare facilities over a two-year period. Patients’ ages ranged from 1 to 91 years and 66% of the patients were reported as male. Also, 8% of the delirium/agitation occurred preoperatively, 8% intraoperatively, and 84% postoperatively. Across all three operative periods, 62% of the reports described dangerous/nonviolent behavior and 26% described dangerous/violent behavior. Additionally, 40% of the event reports described one or more patient injuries (e.g., cardiopulmonary arrest, asphyxiation, hematoma, prolapse/dehiscence, progressive ischemia) and 36% of the patients required additional healthcare services or monitoring (e.g., intra- or interfacility transfer, additional surgical procedure). Finally, 54% of the event reports described patient behavior that created an immediate and high risk of staff harm. Overall, the current study provides novel insight into how delirium/agitation has varying safety implications depending on the operative period. We encourage readers to review Table 5, which proposes a four-phase intervention package to prevent, treat, and de-escalate bouts of delirium/agitation.

Cancellations and Transfers Related to New-Onset Atrial Fibrillation: An Analysis of Survey and Patient Safety Reporting Data From Ambulatory Surgical Facilities

Atrial fibrillation (AF) is a cardiac arrhythmia characterized by an irregular rhythm and often rapid heart rate. People with AF can be symptomatic or asymptomatic and are at increased risk for stroke. In this study, we used two data sources—a survey and Pennsylvania Patient Safety Reporting System (PA-PSRS) reports—to examine new-onset AF in Pennsylvania ambulatory surgical facilities (ASFs). The survey was developed and conducted to learn more about new-onset AF– related cancellations and transfers in Pennsylvania ASFs and to update the Patient Safety Authority ASF Cancellation and Transfer Tracking Tool. The survey response rate was 53.1%, with 50.9% of respondents indicating new-onset AF–related cancellations in the last year. A five-year review of PA-PSRS data revealed an increase in the number of new-onset AF–related cancellation and transfer events that occurred in the last two years. In 70.9% of the reports, patients were 65 years of age and older. A paucity of research on this patient safety issue led us to identify areas for future research.

Nasogastric Tube Placement: A Cross-Comparison of Verification Methods Used in Pennsylvania Hospitals and How They Align With Guidelines

Nasogastric tubes (NGTs) are used as an alternative approach to deliver nutrition and medications, or a method to remove stomach contents. Insertion of these tubes is considered a simple procedure; however, wrong placement or dislodged tubes can lead to patient harm and possibly death. The risk of harm and death increases when misplaced or dislodged tubes are not identified prior to using them. We queried the Pennsylvania Patient Safety Reporting System for events that occurred between January 1, 2017, and June 30, 2020. We analyzed those reports that provided supplemental information describing NGT placement verification methods to determine how these activities aligned with NGT guidelines. The use of X-rays and pH aspirate, guideline-approved verification methods, were identified in 90.8% (544 of 599) of the reports. In 9.2% (55 of 599) of the reports, the use of non-recommended verification methods (e.g., insertion of air bolus/auscultation, were identified). Reports indicated that patients aged less than one year old experienced a higher percentage of non-recommended verification methods being used when compared to all other patients. Interviews with staff at three healthcare facilities discussed their approach to verifying NGT placement. Risk reduction strategies comprise using the guideline recommendations to verify NGT placement and avoiding the use of non-recommended verification methods.

Safety Events Impacting Hospitalized Patients Following Motor Vehicle Crashes: A Qualitative Study of Reports From Pennsylvania Hospitals

Motor vehicle crashes (MVCs) are a significant cause of morbidity and mortality in the United States and around the world. When a patient who has experienced trauma in an MVC presents to the emergency department, they may be unable to participate in their own care due to numerous factors, such as being unconscious, physically incapacitated, or suffering from confusion. To better characterize challenges with care of these patients, we analyzed reports of patient safety events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) related to MVCs, and we identified 282 reports for analysis that occurred from 2018–2020. Patients were more often male (58.9%; 166 of 282) than female (41.1%; 116 of 282), and they ranged in age from 1 to 93 years. A total of 13.1% (37 of 282) of reports were classified as serious events (i.e., events that resulted in patient harm), compared with 2.9% in the full acute care PA-PSRS database. Problems with monitoring or treatment were most common (43.3%; 122 of 282), followed by problems with evaluation (18.4%; 52 of 282), falls (11.7%; 33 of 282), problems with documentation (7.4%; 21 of 282), medication errors (7.4%; 21 of 282), and problems with transfers (6.4%; 18 of 282). Some potential contributing factors included communication breakdowns, lack of policies or protocols or unawareness about existing policies or protocols for treating certain patient populations, and prioritization of conditions related to an MVC over underlying health conditions.

Challenges and Potential Solutions for Patient Safety in an Infectious-Agent-Isolation Environment: A Study of 484 COVID-19-Related Event Reports Across 94 Hospitals

Previous research has shown that patients in infectious-agent isolation are at greater risk for certain types of safety-related events. We conducted a study to explore the relationship between the various types of events that occur in an isolation environment and the associated factors, which may have implications for the likelihood of the event and severity of patient harm. We conducted a query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to identify event reports submitted by acute care hospitals between January 1 and September 30, 2020. We identified 484 relevant event reports from 94 hospitals for inclusion in our descriptive study (excluding near-miss events). We measured the frequency of relationship between categories of safety-related event types and 18 categories of associated factors. Among the seven categories of event types, the most frequently identified were skin integrity (141 of 484, 29%), falls (129 of 484, 27%), and medication-related (78 of 484, 16%). Across all 18 categories of associated factors, which had or may have had an influence on the event type, the most frequent were patient’s mental status (80 of 484, 17%), staff’s time to don personal protective equipment (62 of 484, 13%), and patient’s interference with equipment/supplies (45 of 484, 9%). Overall, our results revealed that the frequency of certain associated factors varied considerably from one event type to another, which indicates that the relation between event types and associated factors should guide selection of risk mitigation strategies. We encourage readers to leverage our results along with Table 9, which provides a list of challenges identified in an isolation environment and potential solutions. We envision hospital staff proactively and systematically using the information in our manuscript to facilitate their evaluation of the isolation environment and prioritization of risk mitigation strategies.

2020 Healthcare-Associated Infections in the Long-Term Care Setting: An Analysis of Reports From Pennsylvania

The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States. In addition to over 3.9 million acute care records, PA-PSRS has collected more than 357,000 long-term care (LTC) healthcare-associated infection reports since 2009. A total of 26,331 infections were reported in 2020, representing a 7.0% decrease from the prior year. The Northeast region of the state had the highest overall infection rate, with 1.29 reports per 1,000 resident days, and the Southeast region had the largest increase in infection rate from the prior year (increased from 0.87 to 1.02). There was a 10.2% increase in respiratory tract infections from 2019 to 2020; however, the other four main infection types decreased (gastrointestinal by 44.6%, device-related bloodstream by 17.0%, skin and soft tissue by 16.5%, and urinary tract by 1.8%). Additionally, of the four infection subtypes that comprise the respiratory tract infections category, all increased from 2019 to 2020 except for pneumonia. The most frequently reported infection subtype in 2020 was cellulitis, soft tissue, or wound infection, although it had the second largest decrease from 2019. The infection rate for catheter-associated urinary tract infections (CAUTI) had the largest increase from 2019 to 2020, and the rate for norovirus had the largest decrease from 2019 to 2020. Infection rates also differed across the various nursing unit types. The seasonal peak for respiratory infections in 2020 occurred in the second quarter, with the exception of influenza, which peaked in the first quarter. Overall, this analysis demonstrates areas in which continued education and infection prevention measures can be applied to further enhance the safety for residents in long-term care facilities.

2020 Pennsylvania Patient Safety Reporting: An Analysis of Serious Events and Incidents From the Nation's Largest Event Reporting Database

Pennsylvania is the only state that requires acute healthcare facilities to report all events of harm or potential for harm. With over 3.9 million acute care event reports, the Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world. Of the 278,548 patient safety event reports submitted by Pennsylvania’s acute care facilities in 2020, 97.2% were from hospitals and 2.7% were from ambulatory surgical facilities (ASFs). The remaining 0.1% were from birthing centers and abortion facilities. The vast majority of the 2020 reports were Incidents (97.0%) rather than Serious Events (3.0%). For each of the last five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, accounting for 32.1% of all submitted acute care event reports in 2020. The second, third, and fourth most frequently reported event types were Medication Error, Complication of Procedure/Treatment/Test, and Fall, accounting for 16.7%, 16.2%, and 11.8% of submitted reports in 2020, respectively. The reporting rates for hospitals in Q1 and Q2 2020 were 32.8 and 31.5 reports per 1,000 patient days, respectively. For ASFs, the reporting rates for Q1 and Q2 2020 were 9.8 and 8.4 reports per 1,000 surgical encounters, respectively.

Trocar-Related Safety Events in Minimally Invasive Surgical Procedures: Risks for Organ and Vascular Complications

A trocar is a hollow device used during minimally invasive surgery that serves as an entry port for optical scopes and surgical equipment. Insertion of this device into the body is determined using anatomical landmarks taking into consideration the patient’s history and physical attributes, e.g., scars or abdominal size. Insertion of the first trocar is the time of highest risk of injury. Intestinal and vascular injuries are two potentially life-threatening injuries that can occur. A retrospective review of trocar-related events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) between January 1, 2014, and June 30, 2020, identified 268 events. Internal organ and vascular injuries accounted for 81.0% of events; trocar site skin integrity injuries, bleeding/hemorrhage, and hernias accounted for 17.2% of events; and vasovagal responses accounted for 1.9% of events. Internal injuries occurring during the initial insertion of the trocar, Veress needle, or incision in preparation for a trocar insertion was reported in 64.5% of events. Adhesions were identified in 13.5% of internal injury events. Many internal injury events identified a single injury; however, in 17 instances patients sustained two trocar-related injuries. Conversion to open surgery, return to the operating room during the same admission, postoperative intensive care unit admission, ambulatory surgical facility transfer to a hospital, readmission, postdischarge return to the operating room, and death are outcomes identified in the event reports.

Challenges with Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height

An accurate patient height is necessary to calculate certain measurements (e.g., body surface area [BSA]) and lab values (e.g., creatinine clearance [CrCl]), which may be needed to assess renal, cardiac, and lung function and to calculate accurate medication doses. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 679 event reports related to an inaccurate patient height. All events were classified by the reporting facility as incidents, meaning that the patient did not sustain an unanticipated injury or require the delivery of additional healthcare services. The most common care area group where an event occurred was outpatient/clinic (35.8%; 243 of 679). Events were categorized as being related to an error in transcription (72.5%; 492 of 679) or measurement (7.4%; 50 of 679), and the remainder were categorized as etiology of error unclear (20.2%; 137 of 679). The most common transcription errors were the use of the wrong unit of measurement, the transposition of another measurement with height, and typographical errors. Inaccurate patient heights most often led to errors in calculation of medication doses or laboratory values. The most common medication class involved in a dosing error was cancer chemotherapy. In order to ensure accuracy of patient height measurements, patients should be measured at the beginning of every healthcare encounter, units of measurement should be consistent from measurement to transcription into the electronic medical record, and estimated patient height should never be relied upon or recorded.

Patient Harm Resulting From Medication Reconciliation Process Failures: A Study of Serious Events Reported by Pennsylvania Hospitals

Medication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020. Serious events related to medication reconciliation were most common among patients 65 years or older (55.9%; 52 of 93). The majority of events (58.1%; 54 of 93) contributed to or resulted in temporary harm and required treatment or intervention. Permanent harm or death occurred as a result of 3.3% (3 of 93) of the events. Admission/triage was the most frequent transition of care associated with events (69.9%; 65 of 93). The most common stage of the medication reconciliation process at which failures most directly contributed to patient harm was order entry/transcription (41.9%; 39 of 93) and resulted most frequently in wrong dose (n=21) or dose omission (n=13). Most events were discovered after the patient had a change in condition (76.3%; 71 of 93), and patients most often required readmission, hospitalization, emergency care, intensive care, or transfer to a higher level of care (58.0%; 54 of 93). Among 128 medications identified across all events, neurologic or psychiatric medications were the most common (39.1%; 50 of 128), and anticonvulsants were the most common pharmacologic class among neurologic or psychiatric medications (42.0%; 21 of 50). Based on our findings, risk reduction strategies that may improve patient safety related to the medication reconciliation process include defined clinician roles for medication reconciliation, listing the indication for each medication prescribed, and for facilities to consider adding anticonvulsants to their processes for medications with a high risk for harm.

An Analysis of Patient Safety Events Submitted by Abortion Facilities in Pennsylvania 2017–2019

Induced abortion, also called elective abortion, therapeutic abortion, and termination of pregnancy, is widely considered a safe procedure, but complications are known to occur. In Pennsylvania, an induced abortion may be performed at an abortion facility as an outpatient procedure, and these facilities are required to report patient safety events to the Pennsylvania Patient Safety Reporting System (PA-PSRS). We extracted 736 events submitted to PAPSRS by abortion facilities from 2017 through 2019 and analyzed these events in order to better understand patient safety concerns at abortion facilities in particular. All patients were female, and they ranged in age from 14 to 47 years, with a median patient age of 27 years (interquartile range = 23 to 31 years). Complications related to an induced abortion comprised the majority of events (71.6%; n=527), followed by unplanned transfers to the emergency department or acute visits to a healthcare facility following an induced abortion (13.9%; n=102). The most common complication associated with induced abortion was an incomplete abortion (i.e., retained pregnancy tissue; n=343); other complications included failed abortions (i.e., a continuing intrauterine pregnancy following an abortion; n=101), infections (e.g., endometritis and pelvic inflammatory disease [PID]; n=45), and surgical complications (e.g., hematometra, uterine perforation, and cervical lacerations; n=66). The remainder of events (14.5%; n=107) described other patient safety events that occurred at abortion facilities, such as documentation failures and medication-related events.

Prone Positioning in Patients With Acute Respiratory Distress Syndrome and Other Respiratory Conditions: Challenges, Complications, and Solutions

Acute respiratory distress syndrome (ARDS) and respiratory failure are characterized by hypoxemia, i.e., low levels of blood oxygen. Infections such as influenza and COVID-19 can lead to ARDS or respiratory failure. Treatment is through supportive measures. In severe cases, patients receive oxygen through a ventilator and, when appropriate, are placed in a prone position for an extended period. A retrospective review of events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) identified 98 prone position–related events in patients with ARDS, respiratory failure, distress, and pneumonia from January 1, 2010, through June 30, 2020; 30 events were associated with COVID-19. Skin integrity injuries accounted for 83.7% (82 of 98) of the events. The remaining events, 16.3% (16 of 98), involved unplanned extubations, cardiac arrests, displaced lines, enteral feedings, medication errors, a dental issue, and posterior ischemic optic neuropathy.

Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities

Wrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database. In the study we identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, we found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania. Also, we revealed that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.

An Analysis of Nonsuicidal Self-Injury Among Children and Adolescents in Inpatient Psychiatric Hospitals and Units in Pennsylvania

Nonsuicidal self-injury (NSSI) is defined as the direct, deliberate destruction of one’s own body tissue to inflict harm or pain without an underlying suicidal intent. NSSI may include such behaviors as cutting, scratching, biting, hitting, and head banging, and excludes suicidal gestures, accidental injuries, indirect self-harm behaviors (e.g., eating disorders or drug abuse), and socially accepted forms of body modification (e.g., piercing or tattooing). NSSI typically begins in adolescents around 13 or 14 years of age, and lifetime prevalence in the adolescent and young adult population is estimated to be 15% to 20%. Although NSSI does not always progress to or predict future suicidal behaviors, there is believed to be a link between the two, which makes this an important patient safety concern. NSSI has been observed in both the community and the clinical setting, although rates of NSSI are higher within the psychiatric population. NSSI may present as a symptom of numerous psychiatric conditions, including anxiety disorders; mood disorders; substance abuse; eating disorders; and personality disorders, such as borderline personality disorder (BPD).5 Although clinicians once considered NSSI primarily in the context of BPD, NSSI was added as a distinct condition in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) in 2013. In 2019, analysts at the Patient Safety Authority (PSA) conducted and published a study of events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) involving patient self-harm in the nonpsychiatric setting.8 However, an analysis of events in PA-PSRS involving selfharm, and more specifically NSSI, in the psychiatric setting had yet to be undertaken. In this study, we conducted an indepth review and analysis of patient safety events involving NSSI among children and adolescents in the inpatient psychiatric setting that took place in 2019. The purpose of this study was to examine patient-specific factors, such as age and gender, as well as other contributing circumstances, such as interpersonal interactions, that may precipitate NSSI in this patient population.

Process Failures That Increase the Risk of Infection Through Respiratory Droplets: A Study of Patient Safety Events Reported by Hospitals Across Pennsylvania

Respiratory pathogens can lead to pneumonia, bronchiolitis, and death. Rapid identification, along with appropriate standard and isolation precautions, are necessary to prevent the spread of infectious agents causing respiratory infections. We analyzed patient safety events reported to the Pennsylvania Patient Safety Reporting System that were related to viruses and bacteria spread through respiratory droplets. An analysis of events that occurred from January 1, 2019, through December 31, 2019, led to the identification of 338 events involving process failures related to recognizing infectious agents that are spread through respiratory droplets, implementing measures to prevent their spread, or providing timely treatment. Detailed analysis of the process failures showed that 54.9% were associated with processes in testing or processing of laboratory specimens; 29.7% were associated with isolation-related procedures; and 15.4% were associated with medications, triage/assessment, documentation/verbal communication, or not providing the standard of care for patients in missed/delayed orders, procedures, or referrals. Implementation of risk-reduction strategies can help to further reduce the spread of pathogens through respiratory droplets in the hospital setting and further enhance patient safety. These strategies include evaluating collection processes for testing/laboratory specimens, consistently using empiric isolation precautions based on initial triage and patient presentation, and evaluating processes for admissions and transfers.

Accidental Choking Among Hospitalized Patients in Pennsylvania: A 15-Year Retrospective Review

Choking occurs when a foreign body becomes lodged in the airway and obstructs respiration. In the United States, over 5,000 deaths were attributed to choking in 2015. Among older adults, food is the most common cause of choking, and the death rate for choking events involving food is seven times higher among older adults than young children. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 545 events related to accidental choking on food, beverages, medications, or other foreign bodies reported from 2004 to 2019. Patients who experienced a choking event were more often female (56%; 306 of 545), and they ranged in age from 6 months to 102 years, with a median patient age of 70 years (interquartile range = 54 to 83 years). Among choking events that specified the substance involved, food was the most common (80%; 424 of 528 events). The most common foods that patients choked on were meat or fish (n=77), sandwiches (n=38), and breads or cakes (n=31). Abdominal thrusts were the most common immediate response described in event reports, attempted in more than half of events (56%; 306 of 545). Prevention of accidental choking may involve timely assessment of risk factors that predispose a patient to choking, including age older than 60 years, tooth loss and presence of dentures, and underlying psychiatric or neurologic illness.

In-Hospital Substance Use and Possession: A Study of Events From 38 Acute Care Hospitals in Pennsylvania

Patients’ substance use and possession at acute care hospitals is an understudied topic. To learn more about this topic, we queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) for events that occurred during calendar year 2018. We identified 106 reports from 38 acute care hospitals (excluding psychiatric, detox, and behavioral health units and facilities) where a patient possessed and/or misused a substance (e.g., heroin, oxycodone, liquor). We analyzed these reports to better understand how hospital personnel attempt to prevent in-hospital substance use and manage patients who are at risk for using a substance. We explored a range of variables, including antecedent conditions and hospital personnel’s actions post- detection of a patient’s substance use or possession. We found that a relatively low percentage of patients (26%) were identified as having a prior history of substance use, despite later using or being in possession of a substance in hospital. In our sample, patients frequently acquired the substances from visitors, more than half of the substances were consumed intravenously, and opioids were the most common substance. The most prevalent actions taken by hospital personnel were conducting searches for substances and paraphernalia, use of a patient sitter or video monitor, moving patients to a different room, and implementing visitor restrictions. Based on our findings and previous research, hospitals should consider increasing their use of substance use disorder (SUD) screening tools, pharmacotherapy, and referring patients to treatment. Overall, our results can help personnel better understand the nature of and strategies that may reduce the likelihood of in-hospital substance use. Keywords: substance use, paraphernalia, substance use disorder, in-hospital, addiction, opioid, risk mitigation, patient safety