Lessons Learned

Cell Phones and Other RF Transmitters May Interfere with Medical Devices

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.


When Technology Owns You
Meaningless Use of Health IT

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 the screen.


ENFit Connectors Are Coming

 ENFit to current feeding tube adapter

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.


Event Report Update

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.


Our legal counsel is not employed by our facility. Can he have access to patient safety work product?
– J.B., a Southern California Hospital

Dear J.B.,

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 Act.


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