“Lessons Learned” is a regular column in the monthly CHPSO Patient Safety News. Examples are
derived directly from event reporting by hospitals, providing the
opportunity to learn from each other’s experiences and
demonstrating one of the benefits of sharing through a PSO.
According to the FDA, an implantable device or medical
implant refers to devices or tissues placed either inside or on
the surface of the body. Implants may be temporary or permanent,
and serve a variety of purposes. Some common examples include:
It is estimated that 20% of patients presenting at emergency
departments have a psychiatric diagnosis. This is not surprising
considering that, in 2014, over 43 million (18%) adults in the
United States experienced a mental, emotional, or behavioral
health related disorder.
CHPSO recently hosted a safe table discussion on
difficult-to-place psychiatric patients, during which
participants discussed several categories of patients. These
patient types —are also found in safety event reports submitted
to the CHPSO database — include:
Recently, CHPSO hosted a safe table, Care of the Conserved
Patient, focused on patients with a Lanterman-Petris-Short [LPS]
conservatorship that is patients with a psychiatric diagnosis
resulting in grave disability. It became abundantly clear during
the discussion that caring for patients with an LPS
conservatorship is often challenging and complex. Good
communication both within and among facilities is key. It is also
essential that organizations have a plan in place for the early
identification of patients with a conservatorship.
According to the
Food and Drug Administration (FDA), there are between 550 and
650 surgical fires in the United States every year. These types
of fires can result in catastrophic consequences including severe
burns, permanent disfigurement and even death. Surgical fires are
an example of an operating room (OR) fire. The American Society
of Anesthesia defines OR fires and surgical fires as follows:
CHPSO recently completed an analysis of safety events submitted
to the database in the first quarter of 2018 from the “Other”
category of safety event reports. The “Other” category is one of
the largest categories of events in the CHPSO database. It is
designed for safety reports that do not fit into any of the eight
categories as outlined by the Agency for Healthcare Research and
Delays in identification and treatment can have catastrophic
consequences for patients with sepsis. At the least, patients may
experience longer than necessary hospital stays from delays in
care. In extreme cases, septic patients may die or may suffer
severe harm, such as amputations, from delays in care.
Information gleaned from safety events submitted to the CHPSO
database can help determine which factors are associated with
delays in sepsis care. Organizations can work with their team to
address the factors contributing to unnecessary delays in sepsis
identification and treatment.
Restraints are sometimes necessary for the protection of the patient or others. As Centers for Medicare and Medicaid Services (CMS) states, “The use of restraint or seclusion must be selected only when less restrictive measures have been judged to be ineffective to protect the patient or others from harm.
Preventing severe morbidity and/or mortality from uncontrolled hemorrhage is a concern for a wide variety of patient populations. Among trauma patients, the American College of Surgeons reports that hemorrhage is the most common cause of death within the first hour of arrival at a trauma center.
According to a Centers for Disease Control and Prevention (CDC) report there were 65.9 million visits to physician offices and five million emergency department visits in 2014 with mental disorders as the primary diagnosis. These data may not come as a surprise since reports from the CDC also indicate an increase in the numbers of adults who report having experienced serious psychological distress.
According to the Centers for Disease Control and Prevention, suicide was the 10th leading cause of death in the U.S. in 2014. Between 2004 and 2014, the suicide death rate increased 21%, from 11.1 to 13.4 deaths per 100,000 resident population. Among adults aged 45–64, suicide death rates increased 27% between 2004 and 2014. Paramedics and law enforcement are typical first responders to suicide attempt or completed suicide cases, and hospital emergency departments receive patients for further care.
Case:A 46-year-old substance-dependent male went to
the Emergency Department for sweating, chest pain and one week of
cough, and the emergency physician had a chest x-ray ordered for
him. The patient was diagnosed with pneumonia and was discharged
with a prescription for an antibiotic. For weeks later, the
patient returned to the ED because he was coughing up blood. The
clinical team completed both a tuberculosis skin test (TST) and
sputum for acid-fast bacilli.
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.
Staff reported problems with patient monitors, but the
equipment worked properly when tested in the biomedical
engineering department. Problem tracking found that patient
monitors experienced intermittent malfunctions mostly on one
particular side of one particular floor, located above a loading
dock. Citizens’ band (CB) or other mobile radio transmissions
from vehicles arriving at the loading dock were strongly
suspected to have been the cause of the patient monitor
interference. Truck drivers were asked to use house phones on
arriving at the hospital, and the problems were resolved.
Rules for abbreviation use generally focus on medication
safety—identifying visual and textual ambiguities that may
confuse other medical professionals. The ISMP List of
Error-Prone Abbreviations, Symbols, and Dose Designations
includes items like IU that could appear like
IV or 10; and
DPT, which could stand for
The following scenario is derived from incidents reported to CHPSO:
A stable, ventilator-dependent patient (KP) was placed in a room across from the nurses’ station. The nurse caring for this patient then received a post-operative patient whose condition was deteriorating. A code was called for the post-op patient and several staff in the area responded to assist. During this emergency, KP’s ventilator tubing had become disconnected and the ventilator started alarming. However, no one responded to the alarm until a custodian passing by approached the nurses’ station and notified the unit clerk that he had noticed an alarm coming from KP’s room for several minutes and wanted to make sure someone was notified. At this point, the clinical staff realized that KP was quickly deteriorating and immediately responded. Unfortunately, they could not resuscitate KP.
Diffuse responsibility is a recognized safety concern in clinical alarm management. In order to manage the large amount of noise in busy and monitored environments, clinicians often “tune out” alarms that are not related to their own patient assignment. There is an underlying assumption that someone else is responding to an alarm associated with another clinician’s patient. Personnel in the area who are not clinicians are intimidated by alarms and assume that a clinician will respond. One approach to solving this issue is to implement the “No Pass Zone.”
Although performing a root cause analysis (RCA) after an adverse
event has become standard practice in many health care
organizations, there is little evidence to support that this
process has improved patient safety.1 Organizational
culture plays a large part in the success of an RCA; there are
fundamental issues in the structure of the RCA process to address
In the quality and patient safety world, we have a tendency to
focus on the complexity of patient care within the hospital
setting. However, a classic study by Forster, et al1, reminds us
that there are many concerns for the complexity of care
post-discharge. Nearly 20 percent of patients experience adverse
events within three weeks of discharge; about 75 percent of which
are preventable. Adverse drug events are the most common
post-discharge complication, with hospital-acquired infections
and procedural complications also causing considerable morbidity.