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Outdated Infusion Pump Software Risk

The British Columbia Patient Safety & Learning System (BCPSLS) recently reported a norepinephrine overdose caused in part by the infusion pump running an outdated version of the pump software. The updated software version contained a fix that would have helped prevent the error from occurring.

Additional information on the hospital’s interdisciplinary investigation can be found on the BCPSLS’s web site.

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Hypoperfusion Major Contributor to Deep Tissue Injury in ICUs

Synopsis: In this population, DTI risk was significantly associated with DBP < 49 mmHg, hemodialysis, or prolonged surgery. The Braden Score was not associated with DTI occurrence rate.

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Time to Reassess: Small Bore Connectors

The worldwide process to design and produce new, safer, small bore connectors is nearing its conclusion. Background information on the need for redesign and the process involved is at www.chpso.org/post/new-connectors-are-coming.

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CHPSO Launches Insight Tool for Members

One million safety events in the CHPSO database was a milestone achieved in part due to NextPlane Solutions creating greater ease and reduced costs for member reporting. Enhanced mining of the database is the next priority for greater predictive intelligence regarding risk. With Next Plane Solutions’ Insight tool, now available to users on the NextPlane Solutions website, members will be able to view trended and de-identified comparative data through a dashboard.

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Alarm Parameters Survey

In 2013, the Joint Commission announced the National Patient Safety Goal on clinical alarm safety where hospitals must make efforts to address alarm fatigue as a priority. The implementation occurs in two phases: the first began in January 2014 and the second began in January 2016.

Ask CHPSO

How Long Should We Retain Patient Safety Work Product?

HIPAA may also apply, in which case the retention period would be the greater of the HIPAA retention policy or the following recommended Patient Safety Work Product (PSWP) retention policy:

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Awards for Achievement in C-Section Rates Mailed to Hospitals

In October, Secretary Diana Dooley of the California Health and Human Services Agency recognized 104 California birthing hospitals for achieving the Healthy People 2020 goal of 23.9 percent or lower for low-risk, first-birth Cesarean sections. These awards were mailed to the 104 hospitals on behalf of Smart Care California, a coalition of public and private health care purchasers that collectively cover more than 16 million people statewide — or 40 percent of all Californians.

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CHPSO Welcomes a New Staff Member

CHPSO is pleased to announce an expansion of our capabilities with the hiring of Jennifer Boehne, PharmD, MHI, MPH. She is an expert in medication safety and pharmacy informatics and has experience working for both vendors and hospitals and health systems across the country. 

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December Safe Table Meetings – Members Only
Nursing CEs offered and can be used for pharmacists

Contact CHPSO if you are interested in attending any of the upcoming safe table meetings:

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Awards for Achievement in C-Section Rates Mailed to Hospitals

In October, Secretary Diana Dooley of the California Health and Human Services Agency recognized 104 California birthing hospitals for achieving the Healthy People 2020 goal of 23.9 percent or lower for low-risk, first-birth Cesarean sections. These awards were mailed to the 104 hospitals on behalf of Smart Care California, a coalition of public and private health care purchasers that collectively cover more than 16 million people statewide — or 40 percent of all Californians.