Recent research by the Pennsylvania Patient Safety Authority has concluded that overrides of medical technology may impact the safety of patients.
The PA Authority analyzed 583 events reported during the period January 2013 to December 2014. Key findings from this analysis:
- The majority (77%) were related to automated dispensing cabinets.
- The most common classes of medications involved antibiotics (12.0%), opioids (12.0%), anticoagulants (7.4%), and high alert medications (26.4%).
Three main issues in this week’s must reads.
… but, first, a parent’s plight with alarm fatigue – it doesn’t just affect caregivers. If you don’t believe that, then this first-hand account from the parent of a sick baby should change the mind of any doubters that alarm fatigue is real – 14 days of muting and ignoring alarms.
1. March is DVT/Blood Clot Awareness Month
Hats off to @ClotBuster and to @LiverWife for tweeting that March is DVT/Blood ClotAwareness Month! Read More
by Michael Wong
(This article first appeared in Becker’s Clinical Quality & Infection Control.)
CMS is considering a proposed quality measure that would require “appropriate monitoring of patients receiving PCA [patient-controlled analgesia].” This measure seeks to address the high number of errors that occur with PCA, which unfortunately research shows happens all too frequently. Read More
PCA-related device events are three times as likely to result in injury or death. As Tim Ritter (Senior Patient Safety Analyst, Pennsylvania Patient Safety Authority) reminds us, “Over the six-year period from June 2004 to May 2010, data collected by Pennsylvania Patient Safety Authority revealed that there were approximately 4,500 reports associated with PCA pumps. Moreover, U.S. Food and Drug Administration’s (FDA) Manufacturer and User Device Experience (MAUDE) database demonstrates that PCA-related device events are three times as likely to result in injury or death as reports of device events involving general-purpose infusion pumps.” Read More
by Michael Wong
Pain control in hospitals using patient-controlled analgesia (PCA) need to be made safer. In this interview with Michael Wong of the Physician-Patient Alliance for Health & Safety (PPAHS), Tim Ritter (Senior Patient Safety Analyst at the Pennsylvania Patient Safety Authority) and Matthew Grissinger (Director, Error Reporting Programs at ISMP) discuss PCA pumps and why reliance on periodic checks by caregivers and pulse oximetry can only catch an adverse event, but not prevent an adverse event from occurring. For patient safety, PPAHS encourages continuous electronic monitoring, including the use of both capnography and pulse oximetry, of all patients using patient-controlled analgesia (PCA). Read More