A Brief Analysis of Telemetry-Related Events

Successful telemetry monitoring relies on timely clinician response to potentially life-threatening cardiac rhythm abnormalities. Breakdowns in the processes and procedures associated with telemetry monitoring, as well as improperly functioning telemetry monitoring equipment, may lead to events that compromise patient safety. An analysis of reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from January 2014 through December 2018 identified 558 events specifically involving interruptions or failures associated with telemetry monitoring equipment or with the healthcare providers responsible for setting up and maintaining proper functioning of that equipment. The analysis highlighted a steady increase in the quantity of event reports associated with telemetry monitoring submitted to PA-PSRS. User errors accounted for nearly half (47.1%, 263 of 558) of events in the analysis. The most common event subtypes included: errors involving batteries in telemetry monitoring equipment (14.0%); errors in which patients were not connected to telemetry monitoring equipment as ordered (12.9%); errors involving broken, damaged, or malfunctioning telemetry monitoring equipment (10.9%); and errors in which patients were connected to the wrong telemetry monitoring equipment (9.0%).

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Patient safety in vitreoretinal surgery: quality improvements following a patient safety reporting system

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2012-301988 ◽

2012 ◽

Vol 97 (3) ◽

pp. 302-307 ◽

Cited By ~ 4

Author(s):

S Chien Wong ◽

Simon P Kelly ◽

Paul M Sullivan

Keyword(s):

Patient Safety ◽

Reporting System ◽

Vitreoretinal Surgery ◽

Quality Improvements ◽

Safety Reporting

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Challenges with Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height

Patient Safety ◽

10.33940/data/2021.3.5 ◽

2021 ◽

pp. 48-57

Author(s):

Elizabeth Kukielka

Keyword(s):

Patient Safety ◽

Lung Function ◽

Creatinine Clearance ◽

Body Surface ◽

Outpatient Clinic ◽

Reporting System ◽

Healthcare Services ◽

Safety Reporting ◽

Dosing Error ◽

Unit Of Measurement

An accurate patient height is necessary to calculate certain measurements (e.g., body surface area [BSA]) and lab values (e.g., creatinine clearance [CrCl]), which may be needed to assess renal, cardiac, and lung function and to calculate accurate medication doses. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 679 event reports related to an inaccurate patient height. All events were classified by the reporting facility as incidents, meaning that the patient did not sustain an unanticipated injury or require the delivery of additional healthcare services. The most common care area group where an event occurred was outpatient/clinic (35.8%; 243 of 679). Events were categorized as being related to an error in transcription (72.5%; 492 of 679) or measurement (7.4%; 50 of 679), and the remainder were categorized as etiology of error unclear (20.2%; 137 of 679). The most common transcription errors were the use of the wrong unit of measurement, the transposition of another measurement with height, and typographical errors. Inaccurate patient heights most often led to errors in calculation of medication doses or laboratory values. The most common medication class involved in a dosing error was cancer chemotherapy. In order to ensure accuracy of patient height measurements, patients should be measured at the beginning of every healthcare encounter, units of measurement should be consistent from measurement to transcription into the electronic medical record, and estimated patient height should never be relied upon or recorded.

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How Safety Is Compromised When Hospital Equipment Is a Poor Fit for Patients Who Are Obese

Patient Safety ◽

10.33940/data/2020.3.4 ◽

2020 ◽

pp. 48-56

Author(s):

Eliabeth Kukielka

Keyword(s):

United States ◽

Reporting System ◽

Healthcare Providers ◽

The United States ◽

Healthcare Facilities ◽

Safety Reporting ◽

Imaging Department ◽

Skin Tears ◽

Hospital Equipment ◽

Surgical Unit

Obesity is common, serious, and costly, and according to recent data, its prevalence is on the rise in the United States. Event reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) indicate that some healthcare facilities do not have the necessary equipment to monitor and care for some individuals in this patient population, leading to embarrassment for patients, delays in care, and injuries to patients. An analysis of 107 events related to monitoring and patient care for patients who are obese submitted to PA-PSRS from 2009 through 2018 showed that imaging equipment, especially MRI and CT scanners, was most often implicated in event reports (49.5%; 53 events); other equipment included stretchers (24.3%; 26 events) and wheelchairs (11.2%; 12 events). Events most often occurred in an imaging department (30.8%; 33 events) or a medical/surgical unit (21.5%; 23 events). Analysts determined that 80 events (74.8%) resulted in a delay in care and that 44 events (41.1%) resulted in temporary harm to the patient, including skin tears and abrasions. Healthcare providers may not be able to prevent delays in care resulting from the unavailability of adequate equipment for patients who are obese, but they may be able to prevent harm and embarrassment for patients through proactive assessment.

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Patient Safety Concerns in COVID-19–Related Events: A Study of 343 Event Reports From 71 Hospitals in Pennsylvania

Patient Safety ◽

10.33940/data/2020.6.3 ◽

2020 ◽

pp. 16-27

Author(s):

Matthew Taylor ◽

Shawn Kepner ◽

Lea Anne Gardner ◽

Rebecca Jones

Keyword(s):

Patient Safety ◽

Laboratory Testing ◽

Associated Factors ◽

Reporting System ◽

Descriptive Study ◽

Healthcare Systems ◽

Positive Patient ◽

Allocation Of Resources ◽

Patient Harm ◽

Safety Reporting

COVID-19 (i.e., coronavirus disease 2019) was declared a pandemic and has had a profound impact on healthcare systems, which may increase the risk of patient harm. We conducted a query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to identify COVID-19–related events submitted by acute care hospitals between January 1 and April 15, 2020. We identified 343 relevant event reports from 71 hospitals and conducted a descriptive study to identify the prevalence of and relationships between 13 categories of associated factors and 6 categories of event outcomes. We found that 36% (124 of 343) of events had more than one associated factor and 24% (83 of 343) had more than one outcome. The most frequently identified factors were Laboratory Testing (47%; 161 of 343), Process/Protocol (25%; 87 of 343), and Isolation Integrity (22%; 74 of 343). The two most frequent outcomes were Exposure to COVID-19 Positive or Suspected Positive Patient (50%; 173 of 343) and Missed/Delayed Test or Result (31%; 108 of 343). Finally, the findings showed that seven of the associated factors had a notable impact on the frequency of Exposure to COVID-19 Positive or Suspected Positive Patient outcome. Overall, we anticipate that the results can be used to identify areas of greatest need and risk, which could help to guide allocation of resources to mitigate risk of patient harm.

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