“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.
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 Quality:
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.
The following are representative cases from the CHPSO database:
A patient requested a dose of an opioid. The nurse refused as she believed it was unnecessary. The patient became irate with the nurse and physically aggressive towards her. A code gray was called.
Sifting through safety reports at your facility in search of significant issues is daunting. CHPSO shares the challenge: we have about 870,000 reports and more arrive daily.
This challenge is also an opportunity, as we aggregate information from hundreds of providers, and can observe patterns and commonalities in risks and causes that may not be obvious at a single site.
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 Demerol-Phenergan-Thorazine or diphtheria-pertussis-tetanus.
We mined the CHPSO database to determine the most commonly reported alarm related incidents. These reported issues align with those identified by The Joint Commission.
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 as well.
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.
Creating a robust database has been a true challenge at CHPSO, as well as other patient safety organizations (PSO) across the nation. There appear to be some common contributing factors to this problem:
Clinical alarm safety has been highlighted by the Joint Commission in recent months as they have identified this as a National Patient Safety Goal (NPSG). CHPSO is analyzing alarm-related reports that have been submitted by our members and is seeing some patterns.
