Lessons Learned

Vancomycin Monitoring Errors

Some patients benefit from vancomycin blood level monitoring. The need to synchronize the blood test with drug administration adds steps to an already-complex medication process, requires interdepartmental coordination (nursing, pharmacy and phlebotomy) and multiplies the likelihood of problems compared to routine antibiotic administration. Indeed, review of CHPSO’s event reports database shows recurring errors with vancomycin monitoring.


Workplace Violence Prevention Planning

Case Example: Two days after being admitted, a patient attempted to light a cigarette in his room. His nurse reminded him that smoking in the hospital is forbidden and that oxygen was nearby making it a dangerous situation. Although he responded in a disrespectful manner, he did not light the cigarette. After the nurse left, however, the patient lit up a cigarette. The nurse smelled the smoke from the hallway and ran into the room, demanding that the patient put the cigarette out immediately. The enraged patient screamed at the nurse and forcibly pushed her away.


Patient Safety Alert: Equipment Failure During Surgery and Replacement Parts

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.


Think Your Patient Went Home With the Right Dose? Check Again.
The following is based on event reports in the CHPSO database:

Post appendectomy, the patient’s mother wrote down the discharge instructions for administering pain medication to her child. She had the right medication and right time, but the wrong dose. Three days later, the mother rushed her child to the emergency department for constipation and shortness of breath. The child survived.


Signs of Improvement

“Are we doing better?” is a loaded question. Measuring what matters for patient safety is particularly challenging. However, there are some useful progress indicators, and one in particular is showing significant improvement in those hospitals reporting events to CHPSO.


Can we use our hospitals’ existing safety event policies for our PSES?
-C.J. –A Hospital in Central California

We suggest that you review the Patient Safety Evaluation System (PSES) templates available to members on the CHPSO website. There are two versions: one concise and one thorough. If you choose to use these templates, we highly advise you review both of them and determine what works best for your facility. The PSES works alongside but does not replace existing policies you may have in place; however, it is possible to include information from existing policies or combine existing policies with the PSES policy.