Correct Knee, Wrong Implant

I showed the surgeon the implant boxes, who confirmed they were the correct ones. The boxes were then opened and handed to the scrub nurse. Shortly after the cement had set, the knee in question didn’t look right. It was a right implant in a left knee. Informed surgeon that the implant was wrong. Surgeon attempted to remove the femoral component and a small piece of the femoral condyle came away that was cemented to the femoral component. At this point, three other surgeons scrubbed to assist.


Hospitals to Receive Snapshot Reports from CHPSO this Month

Each year, CHPSO mails member hospitals a snapshot of their activity with the patient safety organization for the year. Later this month, hospital CEOs and CHPSO contacts will receive feedback — addressing tone, thoroughness, trends and recommendations — on their submitted events along with a dashboard including hospital-specific information on events submitted in 2016, harm scores, top drug classes mentioned in submitted events, participation at safe tables, and the number of newsletter subscribers.

Lessons Learned

Echoes of Past Disasters

Case 1: Two patients were to receive intrathecal methotrexate with fluoroscopic guidance, Patient A in the morning and Patient B in the afternoon. The pharmacist dispensed the two methotrexate doses and the syringe for Patient A was delivered to his ward that morning. However, the syringe was not delivered before Patient A was transported to radiology. When Patient A arrived in the radiology suite, the technician called over to pharmacy looking for Patient A’s medication. In the pharmacy, the tech saw a single syringe labeled for intrathecal use and delivered it to radiology.


“Big Babies” Don’t Always Need a C-Section Delivery

Case: A 28-year old G1 P0 (first pregnancy, no prior births) at 39 weeks is thought to have a large baby. The ultrasound estimated fetal weight (EFW) is 9 lbs. The patient was considered overweight with a BMI of 29 and the total weight gain during pregnancy of 45 lbs. The patient’s glucose screen was negative. The physician recommended a primary Cesarean delivery because the baby was “big” and the mother will most likely end up with a Cesarean regardless. At delivery the baby weighted 7 pounds, 8 ounces.


ENFit Progress

Supply of the new ENFit connectors, designed to increase patient safety by preventing accidental connection of enteral feeding solutions and medications to intravenous lines, continues to improve. Some hospitals, having identified reliable supply of all the devices needed for safe patient care, have switched over to the ENFit connector.

Please fill out a brief CHPSO survey so that we can gather current information on the status of adoption in California and identify where assistance is needed.


If my hospital is part of a HIIN, do I have to submit data to a PSO?

A previous Ask CHPSO article, Does our hospital have to submit event report data to the PSO by January 1, 2017, highlighted how a hospital can fulfill the requirement of the Affordable Care Act to either report to a PSO or have an evidence based initiative based on the evaluation of safety reports. CMS states that HIINs (Hospital Improvement Innovation Network) satisfy the non-PSO reporting option.


Job Board

Quality and patient safety positions at your organization may be listed on the CHPSO Job Board free of charge.