Pennsylvania Patient Safety Research Articles

Harmful Medication Errors Involving Unfractionated and Low-Molecular-Weight Heparin in Three Patient Safety Reporting Programs

External reporting of medical errors a adverse events enables learning from the errors of others in the pursuit of systems-level improvements that can prevent future errors. It is logical to presume that medication errors involving the use of anticoagulants, among the most frequently cited product classes involved in harmful medication errors, would be captured in a variety of patient safety reporting programs. Data on reported errors involving the anticoagulant heparin were reviewed, compared, and aggregated from the databases of three large patient safety reporting programs-MEDMARX, the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, and the University Health System Consortium, together representing more than 1,000 reporting organizations for 2005 Approximately 300,000 medication errors and near misses were reported to the programs, and 10,359-a mean of 3.6% (range, 3.1%-5.5%)-involved heparin products. The proportion of heparin-related reports that involved patient harm ranged from 1.4% to 4.9%. The phase of the medication use process cited most frequently in harmful events was the administration phase (56% of errors leading to harm), followed by the prescribing phase (19% of errors leading to harm). This study represents the first attempt by these three large reporting systems to combine data on a single clinical process. The consistent patterns evident in the reports, such as the percentage of all medication errors that involved heparin, suggests that reporting programs, at least for common events such as medication errors, may reach a point of diminishing returns in which aggregating more reports of a certain type yields no additional insight once a large volume of similar events is captured and analyzed.

Safety After Cardiac Catheterization

The Pennsylvania Patient Safety Authority's 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 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.

IV Infusion Alarms

The Pennsylvania Patient Safety Reporting System (PA-PSRS, pronounced PAY-sirs) 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, this column in AJN from PA-PSRS, informs nurses on issues that can affect patient safety and presents strategies they can easily put into practice. Visit the Web site of Pennsylvania's Patient Safety Authority, at http://patientsafetyauthority.org for information on extravasation of radiologic contrast agents and useful resources in developing extravasation protocols. Refer to "Patient Safety Advisories" in the left-hand navigation menu. Then click on "Advisory Library," select the September 2004 issue of the PA-PSRS Patient Safety Advisory and click on "Extravasation of Radiologic Contrast. "For the original articles 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.

Expressed Breast Milk

The Pennsylvania Patient Safety Reporting System (PA-PSRS, pronounced PAY-sirs) is a confidential, statewide reporting system on the Internet to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, were required to file information on medical errors beginning in June 2004.Safety Monitor, this column in AJN from PA-PSRS, informs nurses on issues that can affect patient safety and presents strategies they can integrate easily into practice.For more information on PA-PSRS, visit the Web site of Pennsylvania's Patient Safety Authority, at www.psa.state.pa.us. For the original articles discussed in this column or for other articles on patient safety, click on "Advisories and Related Resources" in the left-hand navigation menu.This is a periodic column from the Pennsylvania Patient Safety Reporting System.

Obstructive Sleep Apnea: Knowledge to Improve Patient Outcomes

AS PERIANESTHESIA nurses, the importance of a preoperative assessment is elementary. However, how many perianesthesia nurses and health care facilities are including an assessment for sleep apnea as well? This focus is essential because estimates show that more than 80–90% of people with sleep apnea are undiagnosed, 1 Pennsylvania Patient Safety Advisory. Obstructive sleep apnea may block path to a positive postoperative outcome. 2007;4:91-96. Google Scholar and sleep apnea is estimated to affect more than 12 million Americans. 2 National Institutes of Health. Feb 2008. Sleep apnea. Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_WhatIs.html. Accessed May 14, 2008. Google Scholar Although there are three different types of sleep apnea (obstructive, central, and mixed), obstructive sleep apnea (OSA) is the most common form and has major implications for perianesthesia patients. Therefore, OSA will be the focus for this patient safety column. Jacqueline Ross, MSN, RN, CPAN, is the ASPAN Director for Research, and is a Perianesthesia Nurse Consultant and Patient Safety Analyst with TDC, Columbus, OH

“In God We Trust; All Others Bring Data”

INCREASINGLY, HEALTHCARE PROFESSIONALS are being asked not only to explain why they do what they do but also to provide data that demonstrate that their processes are stable and capable of meeting customer expectations. The move away from absolute trust in the medical system and the providers of care to a perspective that demands data as proof of quality and safety represents a fundamental shift in how this nation views the healthcare industry. Dr. Deming's well-known statement seems apropos to this growing focus on healthcare measurement: God we trust; others bring data! The authors of the lead articles in this issue have a very clear and deep understanding of the growing demands for data being placed on healthcare providers. The article by Patrice Spath offers a wonderful framework for understanding the context and evolution of the national movement toward greater data transparency. There is no doubt that organizations such as the Centers for Medicare and Medicaid Services (CMS), the Joint Commission, and even the Agency for Healthcare Research and have set the national stage for a focus on healthcare measurement. If providers had to respond only to these national initiatives, however, they might be able to tame the measurement monster. But this is not the case. A majority of the data demands currently placed on healthcare providers seem to stem not so much from the national organizations that have been engaged in this work for several decades but rather from the growing number of regional, state, and local agencies and organizations that have decided to place their own data requirements on the healthcare industry. For example, in Pennsylvania, the state data commission (the Pennsylvania Health Care Cost Containment Council [PHC4]) has existed since the mid-igSos, yet several years ago, a new piece of legislation (Act 13 of 2002) established the Pennsylvania Patient Safety Authority (PPSA). This independent state agency, according to its website, is charged with, taking steps to reduce and eliminate medical errors. To accomplish this purpose the PPSA is requiring all Pennsylvania-licensed hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities to report what the Act defines as 'serious events' and 'incidents' to the Patient Safety Authority. In turn, the Authority will analyze the collected data to identify trends or systems failures that can be corrected to prevent future serious events and incidents. Make no mistake about it, the PPSA is certainly setting the proper tone for patient safely within Pennsylvania. But when you combine the data requirements of the PPSA with those of the PHC4, and then top it off with CMS, Joint Commission, and a variety of purchaser requirements, you start to get a dear sense of the measurement monster's true size and appetite for data. Although the historical review is valuable for addressing Spam's first recommendation for taming the measurement monster (i.e., getting administrative to understand the measurement evolution and driving forces), it is her second suggestion that is the most critical. Specifically, she recommends that leaders must be personally involved in identifying appropriate measures to gauge individual and organizational practices and supporting efforts to develop and sustain organizational capacity for continual performance improvement. As I read her perspectives on this second point, I found myself reflecting on yet another of Dr. Deming's classic lines: Quality begins with intent, which is fixed by management (Deming 1992, 5). If the of an organization do not become actively involved in the quality measurement journey, then they will most likely find themselves at a destination that was not on their initial road map. Obviously, the details of data collection and analysis should not be part of a senior leader's daily work, but setting the strategic direction and forming the organization's measurement philosophy should be the guiding points for senior leaders. …

Pennsylvania’s Patient Safety Authority

The objective of this article is to improve patient safety by examining the Pennsylvania Patient Safety Authority, which monitors a statewide reporting system for medical errors and issues statewide advisories suggesting methods for reducing the types of medical errors identified on the basis of the analysis of data reported. First, the article explores the foundation for the Patient Safety Authority and discusses how it reflects many of the recommendations by the Institute of Medicine in To Err Is Human. Second, the article examines the legislation that established the Patient Safety Authority. Third, it examines the development and benefits of the Patient Safety Authority worth emulating. Fourth, the article identifies some of the weaknesses of the Patient Safety Authority. Last, the article concludes that the Pennsylvania Patient Safety Authority exemplifies a major step forward on a long and difficult path toward patient safety.