September 30th, 2008

The following is an advisory issued yesterday by the Pennsylvania Patient Safety Authority, on their September report:

Pennsylvania Patient Safety Authority Releases September Advisory

Analysis shows more than 3,800 medication errors may have been prevented if

documented information about the patient was adequately communicated before the

medication was prescribed and given to the patient

HARRISBURG: More than 3,800 preventable adverse drug events are caused

from healthcare providers not having sufficient information about the patient’s

documented allergies before prescribing, dispensing and administering medications,

according to analysis provided in the Patient Safety Authority’s 2008 September Patient

Safety Advisory.

Review of the data submitted to the Authority shows that in 3,813 cases patients

received medications to which they had documented allergies and 61 of those patients

(1.7%) suffered harm as a result of the error. Narcotics and antibiotics were the most

common medications listed in reports and those which caused the most harm to patients

once administered incorrectly.

Types of breakdowns in the communication of allergy information include:

documentation of patients’ allergies on paper but not entered into the organization’s

computerized order-entry systems; allergy information not consistently documented in

expected locations; organizations’ attempts to list every drug allergy on a patient’s

wristband; and allergies arising during episodes of care but not documented in the

medical record or communicated to appropriate staff.

“As with many medical errors there are several factors that come together that

increase the chances of a medical mistake occurring whether it be a medication error or

another type of mistake,” Michael Cohen, RPh, MS, ScD, advisor to the Pennsylvania

Patient Safety Authority and president of the Institute for Safe Medication Practices said.

“The data in these cases clearly shows that many process changes can be made that

involve communication among healthcare providers and the patient to significantly

decrease the risk of a medication error occurring.”

Within the data analysis of the errors, the Authority noted breakdowns in patient

information, including allergies, diagnosis, pre-existing conditions, and current

medication lists and labs that involve breakdowns at each level of the medications-use

process.

“Many of the errors that occurred were due to breakdowns in communication

either when providers were obtaining information from the patient or caregiver or from

other healthcare providers,” Cohen said. “Others happened when providers documented

incorrect information into electronic medical records or entered orders incorrectly into

other medication computer systems.

“If the healthcare provider prescribing the medication to the patient does not

receive accurate information at the time of dispensing the medication from these devices

meant to prevent medication errors, then opportunities for double-checking if the correct

medication has been prescribed is lost,” Cohen added.

The Authority suggests guidance for healthcare providers to implement to ensure

that current and complete allergy information is accurately and clearly collected and

readily available to all practitioners at the point of care when they are prescribing,

dispensing and administering medications. The Authority also offers tips for consumers

to ensure they are protecting themselves from an adverse medical error, particularly if

they are allergic to certain medications.

For more information on medication errors and their significance with allergies go

to the article “Medication Errors Associated with Documented Allergies” of the 2008

September Pennsylvania Patient Safety Advisory at www.psa.state.pa.us.

The Authority’s quarterly 2008 September Advisory contains other articles developed

from data submitted through real events that have occurred in Pennsylvania’s healthcare

facilities. The articles also provide advice and prevention strategies for facilities to

implement within their own institutions. Highlights include:

• Anticoagulation Management Service: Safer Care Maximizing Outcomes: The

Authority has received hundreds of Serious Event reports associated with

anticoagulation (blood thinning) therapy with poor outcomes. The complexity of

administering blood thinners has resulted in patients’ safety being compromised

and has even caused death for some patients. Additional educational tools are

provided that include: a video about the benefits of an anticoagulation

management service program, a link to a sample failure mode and effects analysis

about anticoagulants and self assessment tool provided by the Institute for Safe

Medication Practices (ISMP) and a link to a toolkit provided by the Institute for

Healthcare Improvement (IHI) for safe and effective anticoagulation therapy in all

healthcare settings. In related news, the Joint Commission recently released a

Sentinel Event Alert about sentinel events involving anticoagulants.

• Caring for Pregnant Patients in the Emergency Department: The Authority has

received reports that show mismanagement of pregnant patients in the emergency

department. When a pregnant patient arrives at the emergency department, there

are really two patients. Often the reports show a lack of communication between

emergency and obstetrics services that may put the patient and fetus at risk. Risk

reduction strategies are included.

• Malignant Hyperthermia (MH): A Rare Condition that Can be Deadly if not

Treated Properly: MH is an inherited disorder of the skeletal muscle, triggered in

patients by general anesthetics. The occurrence, while rare, may suddenly develop

with rapid progression of symptoms resulting in death. The Authority has

received 15 reports of MH with one death. Prompt identification and treatment are

essential for a favorable outcome. The focus of prevention is to ensure the drug

used to treat MH is readily accessible and administered quickly enough for

recovery of the patient.

• Hand Hygiene Practices and the Use of Alcohol-Based Sanitizers: The article

stresses the importance of hand hygiene and the additional benefit of using

alcohol-based sanitizers. Recently, the Authority supported the Centers for

Disease Control and Prevention (CDC) in calling for “Clean Hands Week” to

promote better hand hygiene. The article lists system failures and barriers to

effective hand hygiene and components of successful hand hygiene programs.

• Wrong-Site Surgery Quarterly Update: The Authority also gives a quarterly

update on its wrong-site surgery project. The update shows system breakdowns

continue that lead to wrong-site surgery events. Of particular interest, 38 percent

of the new reports are of wrong-site injections. The Authority has completed its

follow-up study with healthcare facilities regarding their wrong-site surgery

protocols and will give a complete update on the study in its 2008 December

Pennsylvania Patient Safety Advisory.

For a copy of the 2008 September Pennsylvania Patient Safety Advisory go to

http://www.psa.state.pa.us/psa/lib/psa/advisories/v5n3september_2008/sep_2008_v5_n3.pdf

For more information on the Pennsylvania Patient Safety Authority, visit the

Authority’s website at www.psa.state.pa.us.