Case 1: Two patients were to receive intrathecal methotrexate
with fluoroscopic guidance, Patient A in the morning and Patient
B in the afternoon. The pharmacist dispensed the two methotrexate
doses and the syringe for Patient A was delivered to his ward
that morning. However, the syringe was not delivered before
Patient A was transported to radiology. When Patient A arrived in
the radiology suite, the technician called over to pharmacy
looking for Patient A’s medication. In the pharmacy, the tech saw
a single syringe labeled for intrathecal use and delivered it to
I showed the surgeon the implant boxes, who confirmed
they were the correct ones. The boxes were then opened and handed
to the scrub nurse. Shortly after the cement had set, the knee in
question didn’t look right. It was a right implant in a left
knee. Informed surgeon that the implant was wrong. Surgeon
attempted to remove the femoral component and a small piece of
the femoral condyle came away that was cemented to the femoral
component. At this point, three other surgeons scrubbed to
Investigators found that scratches, chips, and dents on reusable
medical scopes frequently occur and are havens for blood, tissue,
and bacteria. A new study suggests that damaged scopes are not
amenable to proper cleaning methods, and some damage may be
difficult to identify without enhanced inspection. Evidence of
contamination via bacterial growth in culture may be delayed
beyond 48 hours.
Case report: A patient with hemophilia was receiving both
intravenous coagulation factors for his hemophilia and topical
human recombinant thrombin (Recothrom) to treat surgical wound
oozing. The nurse took both coagulation factor and Recothrom into
the patient’s room. After being interrupted by other urgent care
needs, the nurse picked up the Recothrom and administered it
intravenously. The patient coded but was successfully
resuscitated since the nurse quickly recognized and openly
acknowledged his error, enabling the code team to provide
appropriate timely treatment.
Stools are a common source of falls for patients,
visitors and staff. These chairs are not meant for long-term
seating and are primarily used by staff. However, when left
unattended, patients or their visitors will seek the vacant seat
to rest or relax if all others are occupied. According to the
Agency for Healthcare Research and Quality (AHRQ), between
700,000 and 1,000,000 people in the nation fall in hospitals each
year. Stool falls reported in the CHPSO database were all
unassisted and often led to visits to the ED for fractures or
Opioids were the most commonly mentioned drug class among the CHPSO database. Of all the medication incident reports submitted to CHPSO, opioids were mentioned in 62,157 reports. The second most common drug class was benzodiazepines and non-benzodiazepine hypnotics, with 23,508 reports. Although this is a large drop off from opioids, benzodiazepines/hypnotics should not be overlooked as a source of potential harm.
On April 30, 2016, fifty employees at a Brazilian hospital
received a dose of insulin instead of the influenza vaccine.
The vaccine and the insulin were stored in the same refrigerator,
and were retrieved by a staff member who confused the two
similar-looking vials. The staff member took the wrong box from
Those who received the incorrect, influenza-portioned injection
of insulin were hospitalized. No adverse events have been
Always separate look-alike vials and clearly label.
Differentiation is key.
Dr. Smith hospitalized Mr. Jones, a diabetic with a right below-knee amputation, for treatment and assessment of continuing pain in the left leg. Two days later, Dr. Smith phoned the ward clerk with new orders for Jones. The clerk shared the orders with Jones’ nurse, who was puzzled by the orders: triple the current dose of morphine, ask Dr. Thomas to do a left below-knee amputation, and administer an enema. The nurse called back Dr. Smith to clarify. Dr. Smith denied ever giving such an order.
On July 31 the FDA issued a safety alert encouraging health care facilities to stop using Hospira Symbiq pumps due to cybersecurity concerns. This is not the first alert concerning hospital equipment cybersecurity and certainly will not be the last. If a hospital must temporarily continue using Symbiq pumps until replacements are in place, the following temporary measures should be taken (FDA, 2015):
Several reports in the CHPSO database have pointed to the
inaccessibility of spare surgical parts or tools while a
procedure is in progress. In several cases, unique screwdrivers
or drill bits have broken, or unique-size screws went missing. In
at least one instance, the incision had to be temporarily closed
with an implant partially secured and the patient was scheduled
for re-operation to complete the procedure another day.
Our partner, ECRI Institute, has issued a patient safety alert
concerning bed-exit alarms. Some bed-exit alarms do not
immediately reset after sounding. During the reset process, which
may take several seconds, there may be no indication that the
alarm is not activated. If a patient exits the bed during this
reset interval, the alarm will not sound, increasing the
likelihood of patient injury.
During a CDPH visit, a CHPSO member hospital identified a
potential problem with the packaging and distribution of
Viaspan®, from Teva Pharmaceuticals. The hospital is concerned
that the product can be inadvertently given intravenously.
Viaspan, a solution for the flushing and cold storage of organs
for transplantation, contains about 125 mEq/L potassium.
In the most recent patient safety newsletter, CHPSO wrote about
the new FDA initiative on infusion pump safety. Now, The FDA has
asked Baxter to recall and destroy all of its Colleague pumps.
The Colleague line of pumps have been the subject of several
recalls, but the FDA is not satisfied with Baxter’s plans to
bring the pumps into compliance. Baxter is estimating that this
will cost the company about $0.5B.As of today, used pumps are
still for sale by some third-party distributors (and on eBay!)
In the May edition of CHPSO Patient Safety News we discussed the
risks posed by using the same connector for differing purposes,
such as breathing gases, enteral feeding and neuraxial access.
Two recent publications highlight the seriousness of
misconnections involving enteral tubes.
A CHPSO member hospital, in analyzing the causes of pressure
ulcers in its patients, noted an issue with some air mattresses
that may represent a contributing factor.
The Sizewise Pulsate™ low air loss mattress replacement system is
currently being used at that hospital for patients at risk for
pressure ulcers or with existing pressure ulcers. The
manufacturer states that the mattress combines automatic pressure
adjustment, a friction and shear reducing cover, and
clinician-friendly controls to create an optimal support surface
for wound care treatment and prevention.
This supplement to the original alert serves as a reminder to
clinicians that they should always check and recalibrate air
mattress settings to the patient’s settings when reconnecting.
Mattresses, when unplugged, may revert to a default
setting.Additionally, though not mentioned in the first alert, on
occasion caregivers may use a mattress control unit for a new
patient without remembering to change the settings that were used
for the prior patient.
Due to the broad scope of the recall, we felt it was important to
distribute this alert. Note that the product may be labeled with
the name of the distributor rather than the manufacturer
(“Triad”).Other names used were: Cardinal Health, PSS Select,
VersaPro, Boca/ Ultilet, Moore Medical, Walgreens, CVS and
H & P Industries, Inc., a manufacturer of over-the-counter
products, is voluntarily recalling all Povidine Iodine Prep Pads
due to concerns of contamination with the pathogenic bacterium
Elizabethkingia meningoseptica. Use of contaminated
Povidine Prep Pads could lead to life-threatening infections,
especially in at-risk populations, including neonates, immune
suppressed patients and surgical patients. Treatment options are
limited for Elizabethkingia meningoseptica infections.
Marshals raided H&P Industries, which makes alcohol wipes
and other products distributed by Triad Group. This company was
the source of several recent large-scale recalls and CHPSO
Patient Safety Alerts. The manufacturer ceased production after
yesterday’s raid. Below is a partial listing of the recalled
Interested counsel may join a discussion group that offers
support and an opportunity to learn about the new legal
privileges and challenges of the Patient Safety and Quality
Improvement Act of 2005. You can request to join the
group by following this link: eepurl.com/rKJaf. This group
generally holds conference calls quarterly.