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.”
Eight-month old Maddie Sims was ejected from a car and
transported by EMS to the hospital. She was cyanotic on arrival.
A team of Children’s Hospital Los Angeles (CHLA) techs, nurses
and physicians packed around Maddie’s bedside.
Zero really means Zero and Patient Safety First (PSF) is looking
to engage all PSF participating hospitals in 2014 to have ZERO
Retained Surgical Items. Maybe things are great with your sponge
management practices and you haven’t had any events, BUT there is
continual abrasion between hospital staff and medical staff
around x-ray policies in the OR, needle management strategies, or
cases of retained guidewires, device fragments or a retained
instrument or towel.
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We are pleased to announce that we have received nearly 150,000
event reports to date, and the number of hospitals submitting
events is increasing. Proper analysis of selected events requires
reading the textual narrative involved, which is time-intensive.
Consequently, CHPSO Patient Safety News, formerly issued
monthly, will now be issued every other month. This change is
intended to allow us to provide articles based upon deeper
analysis of the events we are receiving.
The California Hospital Patient Safety Organization is one of the
largest Patient Safety Organizations in the nation, serving
hospitals in the Western United States. CHPSO confidentially
collects and analyzes patient safety data, develops and shares
best practices, and helps individual hospitals accelerate safety
improvement. More than 300 institutions have joined in this quest
to eliminate preventable patient harm. CHPSO collaborates with
hospital associations to ensure an integrated approach.