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.
Our hospital purchased an Electronic Health Record (EHR) two
years ago. We hired a consulting firm to rapidly roll out the
software and, within two months, the hospital went live on the
new EHR. We didn’t have much training and many clinicians were
left guessing where to type in notes or enter vitals. An incident
occurred where laboratory data was displayed with the oldest
value at the top instead of reverse chronological order. A
patient did not receive a statin because the most recent
cholesterol test result was listed at the bottom of the screen.
The physician only reviewed the results that were at the top of
Reducing the risk of tubing misconnection in the health care
setting requires a complete design change with correlating
standards established and adopted across the industry and around
the globe. Enteral devices are the first of all the clinical
applications to undergo this change; the new enteral connectors
can be identified by the word “ENFit” on the label.
December’s release of the CHPSO 2014 annual report, with its
information on lessons learned to date and the amount of data in
the database, stimulated a marked surge in reporting. In Q1 of
2014, there were a total of 138,000 incident reports submitted to
the CHPSO database. As of March 2015, there are a total of
668,000 incident reports. The stream in reports will give CHPSO
and the Hospital Quality Institute an opportunity to produce
robust analyses related to patient safety events.
You may share patient safety work product (PSWP) with health care
providers holding privileges at your institution. You can also
share PSWP with your workforce, which includes employees,
volunteers, trainees, contractors, or other persons whose
conduct, in the performance of work for your organization is
under your organization’s direct control, whether or not employed
by you. These are not considered disclosures under the Patient Safety
We also have a Counsel Discussion Group, with quarterly calls discussing the latest in the law regarding Patient Safety Work Product privilege and PSO participation. Click here to sign up.
In addition to our newsletters, webinars, reports and alerts, you can keep up with the latest in patient safety through social media. CHPSO has a LinkedIn groupwith over 1300 members to date, and an active Twitter feed tweeting tidbits, tips and tidings. Check them out!
These resources are free for members and non-members alike.