Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants

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 Commission collects information on serious events, and then aggregates the learning from those into Sentinel Event Alerts. They are designed to notify the healthcare community about potentials dangers to patients.

Learn more.

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms

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 suspect TB transferred to floor without making staff aware.
    • Patient transferred to ICU from the ED without sharing information that patient was positive for MRSA.
    • Patient directly admitted without informing receiving personnel that swab testing for influenza had come back positive.

Actionable Items to Mitigate Risk

  • Standardize communication during handoffs.
  • Include in the standardized handoffs a summary of the patient’s infectious disease status, including need for precautions.
  • Identify any outstanding testing during handoff.

The Culture Connection

  • Effective handoffs and clear communication among staff members, within and between units, are important components of a strong safety culture.
  • In addition to investigating the clinical components of these events, the organizations should examine any culture factors that impede full and appropriate communication at handoffs.

Resources

CPS Safety Alert/Watch – LIFEPAK 15 Monitor/Defibrillators

BACKGROUND:

  • Stryker Launches Voluntary Field Action for Specific Units of the LIFEPAK 15 Monitor/Defibrillator.
  • Stryker has become aware that certain LIFEPAK 15 Monitor/Defibrillators were reported to experience a lock-up condition after a defibrillation shock was delivered.  This condition is defined as a blank monitor display with LED lights on, indicating power to the device, but no response in the keypad and device functions.
  • The company is contacting customers with impacted devices to schedule the correction of their device(s), which will include an update to the firmware for a component on the System Printed Circuit Board Assembly.

ACTIONS TO TAKE DURING AN EMERGENCY:

  • If a device exhibits the lockup condition during patient use, the steps from the General Troubleshooting Section (page 10-18) of the LIFEPAK 15 Monitor/Defibrillator Operating Instructions should be immediately followed:
    • Press and hold ON until the LED turns off (~5 seconds) Then press ON to turn the device back on
    • If the device does not turn off, remove both batteries and disconnect the device from the power adapter, if applicable.  Then reinsert batteries and/or, reconnect the power adapter, and press ON to turn the device back on.

ADDITIONAL RESOURCES:

CPS Safety Watch/Alert – Violence Against Healthcare Workers

SAFETY ALERT: Violence Against Health Care Workers

Includes:

  • Verbal Threats
  • Hitting
  • Biting
  • Scratching
  • Kicking
  • Stalking
  • Harassment

ACTIONABLE ITEMS TO MITIGATE RISK

  • Review policies and education of staff pertaining to the recognition and de-escalation of hostile and aggressive behavior by patients.
  • Evaluate the need for security personnel and mental health professionals to assist with identification and de-escalation of aggressive behavior.
  • Assess physical work environment to limit/eliminate the possibility of staff working in isolation without escape route in the possibility a patient becomes physically aggressive.

THE CULTURE CONNECTION

  • Ask your staff if they feel comfortable reporting aggressive behavior
  • Encourage staff to use teamwork strategies such as ensuring a second staff member is readily available to assist with procedures where patients have increased risk of becoming aggressive
  • Leadership should evaluate the culture and consider implementing a support system for staff members who feel threatened/intimidated by patients

RESOURCES

Download Here

 

CPS Safety Watch/Alert – Respiratory Compromise

BACKGROUND

Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

Respiratory Compromise creates problems that are often serious and potentially life-threatening, but they are almost always preventable with the proper tools and approach.  Appropriate patient monitoring and therapeutic strategies are necessary for early recognition, intervention and treatment.

Common themes include:

  • Lack of appropriate monitoring and early identification of respiratory compromise
  • Distractions, complacency or failure to identify high risk patients at transitions of care
  • Not anticipating respiratory complications or lack of situation awareness
  • Complications and risks from procedural sedation

ACTIONS TO TAKE:

  • Understand the pathophysiology and clinical factors of respiratory compromise
  • Early identification of patients at risk
  • Appropriate and timely patient monitoring
  • Appropriate and prompt interventions and treatment

 

RESOURCES
*Respiratory Compromise Institute

Thanks to Dr. Brian Froelke, CPS

 

CPS Safety Watch/Alert – Medication Shortages

Medication Shortages:

  • Adversely affect drug therapy
  • Can cause complications in medical procedures
  • Contribute to medication errors
  • Create frustration for providers & patients

ACTIONABLE ITEMS TO MITIGATE RISK

  • Validate details of shortage & check with suppliers
  • Determine stock on hand
  • Determine purchase history & true use
  • Estimate time until shortage impacts agency & length of shortage
  • Identify alternative drug and sources

THE CULTURE CONNECTION

  • Communicate with staff details regarding shortage:
    • Specific drug & effective date/length of shortage
    • Alternative drugs/concentrations
    • Temporary guidelines & processes
  • Utilize teamwork to identify susceptible patient population
  • Review the 5 “R’s” of medication administration (Right medication, Right dosage, Right route, Right patient, Right time)
  • Implement 2-person medication read-back or cross-check policy

RESOURCES

 

Download Printable Version

CPS Safety Watch/Alert: Elopement

TARGET AUDIENCE

  • Nursing, Medical & other Clinical Leaders
  • Clinical Educators
  • Patient Safety/Quality Improvement Leaders
  • Legal/Risk Management
  • And Leaders in:
    • Hospitals
    • EMS
    • LTC
    • Home Care

SAFETY WATCH: ELOPEMENT
Safety Watch v4-2 Elopement

Emergency Services are increasingly dealing with patients who elope prior to receiving care, many times due to lengthy wait times. Patient safety issues associated with these scenarios include increased risk of:

  • Adverse events
  • Misdiagnosis
  • Mental health exacerbation
  • Diversion which can lead to dangerous delays of care

ACTIONABLE ITEMS TO MITIGATE RISK

  • Review/establish an elopement policy
  • Review triage policy/process
  • Identify those at risk for elopement (such as those suffering with psychosis, dementia, drug or alcohol-related conditions)
  • Perform a gap analysis to address issues such as opportunities to reduce risk, assessing staffing, etc.

THE CULTURE CONNECTION

  • Open Communication: Interview staff to see if they have concerns regarding patient elopement
  • Teamwork: Develop a communication tool that will inform all ED staff of a high risk elopement patient.
  • Share: Openly share peer-reviewed best practices from the literature and processes that have been implemented at your facility or other facilities.

RESOURCES

NEXT STEPS

  • Share this watch with the target audience
  • Promote daily safety briefings
  • Continue to share incidents, near misses and unsafe conditions with the Center for Patient Safety

The Joint Commission released Sentinel Event Alert #57

The Joint Commission released Sentinel Event Alert #57 this week:  The Essential Role of Leadership in Establishing a Patient Safety Culture.

The Center for Patient Safety supports the 11 patient safety tenets and provides services and supports to help health care providers across the continuum improve patient safety.  For additional information contact us.

CPS PSO Watch/Alert: Fall Risk

The Center for Patient Safety issues this alert regarding falls based on our data analysis.

Falls are a difficult and long-standing challenge for providers. While the majority of events report no harm, falls continue to result in severe life-changing injury or even death.  The CPS recommends you re-evaluate your fall risk program, considering the following best practices:

  • Ensure the fall risk assessment tool correlates to the daily workflow and all nurses are trained in appropriate utilization of the tool
  • Include all staff (dietary, housekeeping, maintenance personnel also) and physicians in your falls prevention program
  • Utilize a standardized communication tool to communicate the patient’s fall risk potential to the entire team
  • Make certain the preventative measure match the patient’s risk factors
  • Individualize/tailor preventative measures to meet the patient’s needs (i.e. bed alarms are not effective for all patients)
  • Include consistent patient rounding as part of your preventative measures
  • Implement a quick post-fall huddle process to quickly identify contributing factors that require a system/program change
  • Routinely/daily review medications and their effect on each patient’s fall risk potential

This alert is provided to increase awareness regarding the complex considerations required for a successful falls prevention program.

 

Resources:

http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

http://www.patientsafety.va.gov/professionals/onthejob/falls.asp

http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxman1.html

http://centeronaging.med.miami.edu/documents/Evidence-BasedStrategiestoReduceFallRisk.pdf

http://www.champ-program.org/static/Falls_BPIP.FromHHQIWebsite.pdf

https://www.cdc.gov/steadi/

CPS Safety Watch/Alert: Bariatric Patients

According to the latest data published by the CDC in September 2015, more than 1/3 of the adult population is considered obese.  Coupled with often other complex health conditions this growing patient population brings with it new challenges for the EMS provider.
Based on industry data and recent findings from event data being submitted to the PSO, the Center for Patient Safety is issuing a Safety Watch as these patients have been found to have an increased risk of:

  • airway related events
  • stretcher related events or other device failure-related events
  • patient handling, including lifting and safely moving the patient
  • medication mistakes

Some suggested safe practices include:

  • Maintain the appropriate equipment and training for the bariatric patient.
  • When moving a patient, ensure the appropriate number of personnel are present (at minimum 4 persons for patients weighing more than 300 pounds).
  • Communicate with the receiving or destination hospital to ensure appropriate equipment and staffing are available for the transition of care.  Consider an alternative destination or contingency plan if the primary receiving facility does not have the necessary equipment or staffing to provide the safe transition of care.
  • Discuss this patient population with your medical director for specific needs, equipment or other requirements.

Resources:

http://www.cdc.gov/obesity/data/adult.html

http://www.boundtreeuniversity.com/Patient-handling/articles/1320927-Managing-and-moving-the-very-large-EMS-patient

http://www.fireengineering.com/articles/print/volume-165/issue-5/departments/fire-service_ems/treatment-transport-of-bariatric-patients.html

http://www.emsworld.com/article/10654895/prehospital-bariatric-care

Downloadable version

BLOG:

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

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

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

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

CPS Safety Alert/Watch – Culture can Improve the Control of Multi-Drug Resistant Organisms:

ISSUE:A number of events reported to CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status.Examples include:~Patient with s

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RESOURCES:

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.