Sometimes health care providers do not recognize the ever-growing opioid problem as one they should address. Think again! Read Health Affair’s blog with suggested resources that providers and the community can use. Together we can address this!
Annually, the majority of events submitted to the Center for Patient Safety’s PSO result in no harm to the patient, however, there is a steady increase in events reported to the PSO which supports continued learning. With nearly 35,000 events from healthcare organizations, medication events continue to be the highest reported event type, followed by falls.
Accurate medication reconciliation is a challenge. There are near misses and patient events reported to the Center’s database related to errors which occurred because the reconciliation process was either skipped or not done properly. In one case, a patient received another patient’s medications in error because they had been entered in the wrong medical record. Due to the patient’s underlying renal failure, the incorrect medications exacerbated the condition, resulting in death.
LESSON LEARNED
Streamline the reconciliation process as much as possible, but ensure that staff understand the importance of completing it accurately for every patient and follow the “5 Rs”:
REMINDER
PSO adverse event reporting cannot be used for comparison of individual organizations. The purpose of PSO adverse event reporting is to learn what events occur and why, and to use that information to prevent future occurrence and patient harm. The value is in the quantity, quality, and details. The more reports obtained by the PSO containing detailed information about errors, near misses, and unsafe conditions, the greater potential for learning, sharing, and proactively preventing future harm, costs, and liability exposure.
Find out more about Patient Safety Organizations (PSOs)
A recording of AHRQ’s May 20 CE Webinar exploring hospital-based medication reconciliation intervention to reduce medication errors in transitions of care is now available. The webinar shares successful strategies such as pharmacist-led processes to prevent medication error and adverse drug events. Also available is an AHRQ report on the topic and the MATCH toolkit, a step-by-step guide to improve the process that are also discussed on the Webinar.
The Agency for Healthcare Research and Quality has released a toolkit “Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.” The toolkit is designed to facilitate the reduction of patient harm due to adverse drug events or medication errors. AHRQ suggests the following advantages:
The toolkit is designed to help acute care and post-acute care facilities evaluate and improve their current medication reconciliation process. Check it out today!
A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour
The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis
Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with
The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.