Pennsylvania Patient Safety Authority data shows that patients experiencing a life-threatening situation in a healthcare facility may be more at risk due to a lack of correct equipment and supplies readily available to adequately treat the emergency
Healthcare facilities sometimes lack the appropriate equipment and supplies to successfully manage an emergency in their facility in a timely manner, according to data released today by the Pennsylvania Patient Safety Authority and published in the June Pennsylvania Patient Safety Advisory.
The Authority conducted a data review over a 12-month reporting period (2008) identifying 56 reports that highlighted emergency or rapid response situations in which supplies or equipment were missing or outdated.
While the locations of these events varied, as did the types of medical emergencies, a common theme in the reports was a lack of appropriate equipment and supplies to successfully manage the emergency in a timely manner. Thirty-five reports referenced issues with emergency carts and 21 referenced issues with missing supplies or malfunctioning equipment during an emergency situation.
"The Authority's data shows that some healthcare facilities are not always ready when a life-threatening emergency occurs to a patient in their facility," Mike Doering, executive director of the Pennsylvania Patient Safety Authority said. "There are guidelines facilities can adopt to help facilities prepare for a medical emergency so that if one occurs, the best possible life-saving techniques and equipment will be available to try to save the patient."
Some descriptions of reports and the care areas where the emergencies occurred are listed in the Advisory showing the wide range of emergency situations and locations. They include:
Report 1: [Location: Emergency Department]
During rapid response, a patient needed to [have a tube placed in him] and the intubation box had no stylet [a slender surgical probe]. The RN needed to go to another unit to get a box with a stylet. The patient's intubation was delayed five to eight minutes.
Report 2: [Location: Medical/Surgical/Cardiac Intermediate Unit]
Code was called for this patient. [Staff] did not call to have the [code] cart replaced until [late afternoon]. Cart was not cleaned up before the exchange, and used needles and a blade were left lying on top the cart. Medications were used also. [There was a] safety concern with a partial cart on the floor for five hours.
Report 3: [Location: Medical Intensive Care Unit]
The patient's heart rate was greater than 160 beats per minute and sustained. Following American Heart Association advanced cardiac life support guidelines, adenosine was [administered intravenously]. There was not adequate stock of adenosine in crash cart to give recommended protocol. The patient was transferred to the ICU and cardioverted [shocked]. A normal heart rhythm was obtained.
Report 4: [Location: Outpatient Area]
[The patient] became unresponsive. The rapid response team was called. The code cart was brought, but then taken away. Supplies to treat the patient, including intravenous (IV) supplies were not available.
"Along with pointing out the obvious that healthcare facilities are not always prepared for an emergency situation, some reports also show that hospital staffs are reporting that crash carts are not adequately supplied even if an event did not occur where a patient was involved," Doering said. "These reports give all healthcare facilities the opportunity to take a second look at their rapid response protocols to ensure everything that can be done is being done to provide a positive outcome in an emergency situation."
The three distinct factors of rapid response preparedness that must be addressed in almost every clinical area include: 1) quick access to working equipment and up-to-date supplies; 2) knowledgeable and trained staff to manage the clinical emergency; and 3) after systems are in place, maintaining a state of readiness to manage a clinical emergency at any time.
Along with more strategies to improve rapid response preparedness, the Authority offers a sample checklist for facilities to readily implement the first factor. For a copy of the sample checklist or more information on rapid response preparedness, go to the Advisory article, "Clinical Emergency: Are You Ready in Any Setting?" at the Authority's website www.patientsafetyauthority.org.
The Authority's quarterly 2010 June Advisory contains other articles developed from data submitted about 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:
- Improving the Safety of Blood Transfusions: Blood component transfusions to the wrong patient occur in about 1 of 10,000 transfused units. Two-thirds of these errors are associated with incorrect blood recipient identification occurring at the patient's bedside. The Authority received 535 reports of blood transfusion-related events during the 13-month period from July 2008 through July 2009. Reports involved mismatched units; events related to blood component collection; blood products dispensed, distributed or administered; or wrong patients being transfused. This article focuses on the process for safe transfusion and the risk reduction strategies that decrease the incidence of transfusion errors. The Authority also provides healthcare providers with a reprinted, sample diagram of the process on its website under "Educational Tools."
- Tubing Misconnections: Making the Connection to Patient Safety: When patients must have multiple tubing lines connected to them for various reasons, there is an increased risk for a tubing misconnection. Between January 2008 and September 2009, 36 events of tubing misconnections were reported to the Authority. Strategies to prevent tubing misconnections are provided in this article.
- Management of MRSA in Ambulatory Surgical Facilities: Patient Safety Officers in ambulatory surgical facilities reached out to the Authority through their Patient Safety Liaison asking for help in managing MRSA patients in their facilities. In response to their request, the Authority conducted a series of MRSA management workshops between April and October 2009 for a total of 57 ASFs spanning three regions-Northeast, Central and Northwest. Attendees of the program provided feedback through a survey which revealed almost 90% were highly satisfied with the workshop and felt it was applicable to their facility. The Authority is scheduling MRSA workshops in the Southwest and Southeast regions.
- Wrong-Site Surgery Quarterly Update: The number of wrong-site surgeries in Pennsylvania increased during the first quarter of 2010 despite the availability of evidence-based best practices. Wrong-site anesthetic blocks were the most commonly reported (3), with two reports of wrong vertebral level and two reports of wrong-site procedures on the breast. The Authority has begun an onsite consultation program for Pennsylvania facilities that wish to analyze their vulnerabilities for wrong-site surgery. Requests can be made through the Authority office or the regional Patient Safety Liaison. A wrong-site surgery toolkit is also available for facilities and consumer tips for patients.
Pennsylvania Patient Safety Authority