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

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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Allergy-Related Medication Error Reports Submitted to a Large Patient Safety Reporting System

Patient Safety ◽

10.33940/medical/2019.9.3 ◽

2019 ◽

pp. 18-27

Author(s):

Matthew Grissinger ◽

Michael Gaunt ◽

Alexander Shilman

Keyword(s):

Patient Safety ◽

Medication Error ◽

Drug Allergy ◽

Reporting System ◽

Medication Use ◽

Patient Harm ◽

Event Reporting ◽

Safety Reporting ◽

Large Patient ◽

Allergy Drug

Medication allergies can and do cause patient harm. Managing a patient’s allergies is a challenge for institutionsbecause failures can happen throughout the medication-use process. A total of 854 Medication Error events associated with patient allergies that occurred between July 2016 and June 2018 were reported through a large event reporting database. Analysts categorized these events into the following five stages: obtaining information from the patient, documenting allergies in the record, ordering medications, verifying orders, and administering medications. More than half (56.3%; n = 481) of the events reached the patient. Most likely to reach patients were events involving breakdowns when obtaining information from the patient (74.7%, n = 68 of 91) and administering medications (97.6%, n = 281 of 288). In reports that indicated allergies were properly documented, the majority (87.3%, n = 289 of 331) of the events that reached patients passed through two or more stages. Organizations may use this information to inform proactive efforts to implement system-based strategies to improve the medication-use process. Keywords: drug allergy, drug reaction, medication errors, medication safety, patient safety

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Safety Events Impacting Hospitalized Patients Following Motor Vehicle Crashes: A Qualitative Study of Reports From Pennsylvania Hospitals

Patient Safety ◽

10.33940/data/2021.9.2 ◽

2021 ◽

pp. 18-27

Author(s):

Elizabeth Kukielka

Keyword(s):

Patient Safety ◽

Reporting System ◽

Motor Vehicle ◽

The United States ◽

Motor Vehicle Crashes ◽

Vehicle Crashes ◽

Patient Harm ◽

Contributing Factors ◽

Safety Reporting ◽

Communication Breakdowns

Motor vehicle crashes (MVCs) are a significant cause of morbidity and mortality in the United States and around the world. When a patient who has experienced trauma in an MVC presents to the emergency department, they may be unable to participate in their own care due to numerous factors, such as being unconscious, physically incapacitated, or suffering from confusion. To better characterize challenges with care of these patients, we analyzed reports of patient safety events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) related to MVCs, and we identified 282 reports for analysis that occurred from 2018–2020. Patients were more often male (58.9%; 166 of 282) than female (41.1%; 116 of 282), and they ranged in age from 1 to 93 years. A total of 13.1% (37 of 282) of reports were classified as serious events (i.e., events that resulted in patient harm), compared with 2.9% in the full acute care PA-PSRS database. Problems with monitoring or treatment were most common (43.3%; 122 of 282), followed by problems with evaluation (18.4%; 52 of 282), falls (11.7%; 33 of 282), problems with documentation (7.4%; 21 of 282), medication errors (7.4%; 21 of 282), and problems with transfers (6.4%; 18 of 282). Some potential contributing factors included communication breakdowns, lack of policies or protocols or unawareness about existing policies or protocols for treating certain patient populations, and prioritization of conditions related to an MVC over underlying health conditions.

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Clinical Cybersecurity Training Through Novel High Fidelity Simulations (Preprint)

10.2196/preprints.9853 ◽

2018 ◽

Author(s):

Christian Dameff ◽

Jordan Selzer ◽

Jonathan Fisher ◽

James Killeen ◽

Jeffrey Tully

Keyword(s):

Patient Safety ◽

Patient Care ◽

Medical Devices ◽

Healthcare Systems ◽

High Fidelity ◽

Protected Health Information ◽

Patient Harm ◽

Security Vulnerabilities ◽

Clinical Simulations ◽

Medical Infrastructure

BACKGROUND Cybersecurity risks in healthcare systems have traditionally been measured in data breaches of protected health information but compromised medical devices and critical medical infrastructure raises questions about the risks of disrupted patient care. The increasing prevalence of these connected medical devices and systems implies that these risks are growing. OBJECTIVE This paper details the development and execution of three novel high fidelity clinical simulations designed to teach clinicians to recognize, treat, and prevent patient harm from vulnerable medical devices. METHODS Clinical simulations were developed which incorporated patient care scenarios with hacked medical devices based on previously researched security vulnerabilities. RESULTS Clinician participants universally failed to recognize the etiology of their patient’s pathology as being the result of a compromised device. CONCLUSIONS Simulation can be a useful tool in educating clinicians in this new, critically important patient safety space.

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A Brief Analysis of Telemetry-Related Events

Patient Safety ◽

10.33940/biomed/2019.12.4 ◽

2019 ◽

pp. 42-50

Author(s):

Elizabeth Kukielka ◽

Kelly Gipson ◽

Rebecca Jones

Keyword(s):

Patient Safety ◽

Cardiac Rhythm ◽

Reporting System ◽

Healthcare Providers ◽

Steady Increase ◽

Monitoring Equipment ◽

Safety Reporting ◽

Common Event ◽

Life Threatening ◽

Compromise Patient Safety

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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Risk of Medication Errors With Infusion Pumps

Patient Safety ◽

10.33940/biomed/2019.12.7 ◽

2019 ◽

pp. 61-69

Author(s):

Matthew Taylor ◽

Rebecca Jones

Keyword(s):

Medication Error ◽

Medication Errors ◽

Reporting System ◽

Risk Mitigation ◽

Infusion Pump ◽

Free Text ◽

Patient Harm ◽

Infusion Pumps ◽

Safety Reporting ◽

Medication Process

The risk of medication errors with infusion pumps is well established, yet a better understanding is needed of the scenarios and factors associated with the errors. Our study explored the frequency of medication errors with infusion pumps, based on events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) during calendar year 2018. Our study identified a total of 1,004 events involving a medication error and use of an infusion pump, which occurred at 132 different hospitals in Pennsylvania. Fortunately, a majority of medication errors did not cause patient harm or death; however, we did find that 22% of events involved a high-alert medication. Our study shows that the frequency of events varies widely across the stages of medication process and types of medication error. In a subset of our data, we manually reviewed a free-text narrative field in each event report to better understand the nature of errors. For example, we found that a majority of wrong rate errors led to medication being infused at a faster rate than intended, and user programming was the most common contributing factor. Overall, results from our study can help providers identify areas to target for risk mitigation related to medication errors and the use of infusion pumps.

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