PENNSYLVANIA PATIENT SAFETY ADVISORY
An Independent Agency of the Commonwealth of PennsylvaniaPEN N S Y LVA N I APATI EN TSA FET YA DV I SORYProduced by ECRI Instituteand ISMP under contractto the PennsylvaniaPatient Safety AuthorityVol. 13, No. 1March 2016REVIEWS & ANALYSESFOCUS ON INFECTION PREVENTION124Family Members Advocate for ImprovedIdentification of Patients with Dementia in theAcute Care SettingA patient’s family member contacted the Pennsylvania PatientSafety Authority about several “near miss” patient safetyevents in which hospital staff obtained inaccurate informationfrom the patient, unaware of his dementia diagnosis. Riskreduction strategies targeting failure modes include screeningfor dementia, assessing capacity, identifying and communicating with surrogate decision makers, and standardizingcommunication of a patient’s diagnosis with all hospital staff.11Missed Respiratory Therapy Treatments:Underlying Causes and Management StrategiesEvents reported to the Pennsylvania Patient Safety Authorityand a statewide survey of respiratory therapists provided afoundation to understand why missed respiratory treatmentsoccur. Tracking the reasons for missed treatments is the firststep to better understand facility-based trends and may guidemanagers as they consider methods to coordinate care anddevelop time-driven standards.18The relationship between achievement, avoidance of failure,and personal risk in terms of worker compliance with isolation and related procedures is examined. Situational andisolation precaution awareness are explored to describehealthcare-worker behavior in an environment where isolationprecautions are indicated.FROM THE DATABASE29Decline in Serious Events and Wrong Drug ReportsInvolving Opioids in Pennsylvania FacilitiesUPDATE32The Forgotten Tourniquet—An UpdateOTHER FEATURES36Authority Recognized Healthcare Providers areCommitted to Patient Safety39More than Complicated, Healthcare Delivery isComplex, Adaptive, and EvolvingMedication Errors Involving Healthcare StudentsThe extent to which healthcare students are involved inmedication errors is relatively unexplored. Professional organizations, healthcare facilities, and professional schools canhelp reduce the risk of student-involved errors by implementing key strategies, including incorporation of didactic andexperiential medication safety content into school curriculaand on-site training programs.A Conceptual Framework for Improving IsolationAwareness in Pennsylvania Acute Care Hospitals
OBJECTIVEThe Pennsylvania Patient Safety Advisory providestimely original scientific evidence and reviews ofscientific evidence that can be used by healthcaresystems and providers to improve healthcaredelivery systems and educate providers about safehealthcare practices. The emphasis is on problems reported to the Pennsylvania Patient SafetyAuthority, especially those associated with a highcombination of frequency, severity, and possibilityof solution; novel problems and solutions; andproblems in which urgent communication ofinformation could have a significant impact onpatient outcomes.PUBLISHING INFORMATIONThe Pennsylvania Patient Safety Advisory (ISSN1941-7144) is published quarterly, with periodicsupplements, by the Pennsylvania Patient SafetyAuthority. This publication is produced byECRI Institute and the Institute for Safe Medication Practices under contract to the Authority.COPYRIGHT 2016 BYTHE PENNSYLVANIA PATIENTSAFETY AUTHORITYThis publication may be reprinted and distributed without restriction, provided it is printedor distributed in its entirety and without alteration. Individual articles may be reprinted intheir entirety and without alteration, providedthe source is clearly attributed.Current and previous issues are available onlineat http://www.patientsafetyauthority.org.SUBSCRIPTION INFORMATIONThis publication is disseminated by e-mail at nocost to the subscriber. To subscribe, go tohttp://visitor.constantcontact.com/d.jsp?m 1103390819542&p oi.INDEX INFORMATIONThe Pennsylvania Patient Safety Advisory isindexed in NLM Catalog (http://www.ncbi.nlm.nih.gov/nlmcatalog), a service of the USNational Library of Medicine and NationalInstitutes of Health.The Advisory is also indexed in the CINAHL Plus and CINAHL Plus with Full Text databases.CONTINUING EDUCATIONThe Pennsylvania Patient Safety Authority workswith the Pennsylvania Medical Society to offerAMA PRA Category 1 Credits for selectedportions of the Pennsylvania Patient Safety Advisorythrough the online publication Studies in PatientSafety. Go to http://www.pamedsoc.org to findout more about patient safety continuingmedical education opportunities.The Authority also works with the PennsylvaniaState Nurses Association to offer nursing continuing education credits for selected portionsof the Advisory. Go to https://psna.hostingharrisburg.com to view the course catalog.CONSIDERATION OFSUBMITTED MANUSCRIPTSManuscripts consistent with the objectives ofthe Pennsylvania Patient Safety Advisory arewelcome. For information and guidance aboutsubmission and instructions for authors, pleasecontact the editor.Scan this codewith yourmobile device’sQR reader tosubscribe toreceive theAdvisory for free.Page iiPATIENT SAFETY AUTHORITYBoard of DirectorsRachel Levine, MD, ChairRadheshyam M. Agrawal, MDJan Boswinkel, MDJohn Bulger, DO, MBADaniel Glunk, MDLorina Marshall-BlakeCliff Rieders, Esq.Stanton Smullens, MDEric H. Weitz, Esq.Contact InformationMailing address: PO Box 706Plymouth Meeting, PA 19462-0706Telephone: 866-316-1070Fax: 610-567-1114E-mail: support papsrs@pa.govEditorial Advisory BoardMary Blanco, RN, MSN, CPHQ, Brandywine HospitalLawrence M. Borland, MD,Children’s Hospital of Pittsburgh of UPMCDorothy Borton, RN, BSN, CIC, Einstein Healthcare NetworkAlbert Bothe Jr., MD, Geisinger Health SystemStaffMichael Doering, MBA, Executive DirectorMark E. Bruley, BS, CCE, ECRI InstituteLaurene Baker, MA, Director of CommunicationsVincent Cowell, MD, Temple UniversityRegina M. Hoffman, RN, BSN, MBA, CPPS,Frank M. Ferrara, MD, MBA,Director of Educational Programs, Interim AssistantWills Eye Surgery Center-PlymouthExecutive DirectorCaprice C. Greenberg, MD, MPH, University of WisconsinChristina Hunt, MSN, MBA, HCM, RN, CPPS,Daniel Haimowitz, MD, FACP, CMDDirector of Collaborative ProgramsMary T. Hofmann, MD, Abington Hospital—Jefferson HealthHoward Newstadt, JD, MBA, Finance Director/CIOJanet Johnston, RN, MSN, JDMegan Shetterly, RN, MS, CPPS, Senior Patient Safety Liaison Sandra Kane-Gill, PharmD, MSc, FCCM, FCCP,University of Pittsburgh School of PharmacyJoAnn Adkins, BSN, RN, CIC, Infection Prevention AnalystHarold S. Kaplan, MD, Mount Sinai School of MedicineMichelle Bell, RN, BSN, FISMP, CPPS,Michael L. Kay, MD, Wills Eye Hospital, Thomas JeffersonPatient Safety LiaisonUniversity Hospital, Pennsylvania HospitalJeffrey Bomboy, RN, BS, CPPS, Patient Safety LiaisonJohn J. Kelly, MD, FACP, Abington Hospital—Jefferson HealthKelly R. Gipson, RN, BSN, Patient Safety LiaisonCurtis P. Langlotz, MD, PhD, University of PennsylvaniaRebecca Jones, MBA, BSN, RN, CPHRM, CPPS, PatientMichael Leonard, MD, Kaiser Permanente,Safety LiaisonInstitute for Healthcare ImprovementRichard Kundravi, BS, Patient Safety LiaisonJames B. McClurken, MD, FACC, FCCP, FACS,Melanie A. Motts, RN, BSN, MEd, Patient Safety LiaisonTemple UniversityTerri Lee Roberts, BSN, RN, CIC, Infection PreventionPatrick J. McDonnell, PharmD,AnalystTemple University School of PharmacyRobert Yonash, RN, CPPS, Patient Safety LiaisonDwight McKayTeresa Plesce, Office ManagerFrancine Miranda, RN, BSN, FASHRM, Lehigh Valley HospitalKaren McKinnon-Lipsett, Administrative SpecialistDona Molyneaux, PhD, RN, Gwynedd-Mercy CollegeShelly M. Mixell, Executive Director AssistantGina Moore, RN, BSN, CPHQ, Christiana Care Health ServicesSteve D. Osborn, Vice President, Saint Vincent Health CenterContact Information333 Market Street, Lobby LevelChristopher M. Pezzi, MD, FACS, Abington Hospital—JeffersonHarrisburg, PA 17120HealthTelephone: 717-346-0469Eric Shelov, MD, Children's Hospital of Philadelphia,University of PennsylvaniaFax: 717-346-1090Website: http://www.patientsafetyauthority.orgHyagriv N. Simhan, MD, MSCR, University of PittsburghE-mail: patientsafetyauthority@pa.govDean Sittig, PhD, University of TexasAmy B. Smith, PhD, Lehigh Valley Health NetworkPENNSYLVANIA PATIENTDonald P. Underwood, DO, Drexel UniversityNielufar Varjavand, MD, Drexel UniversitySAFETY ADVISORYDebra J. Verne, MPA, RN, CPHRM, Penn StateEllen S. Deutsch, MD, MS, FACS, FAAP, CPPS, EditorMilton S. Hershey Medical CenterJohn R. Clarke, MD, Editor EmeritusLinda Waddell, MSN, RN, CPPS, CJCP, Donald D. Wolff, Jr.,William M. Marella, MBA, MMI, Program DirectorCenter for Quality Improvement and Innovation at UPMCAnalystsHarold C. Wiesenfeld, MD, University of PittsburghTheresa V. Arnold, DPM, Manager, Clinical AnalysisZane R. Wolf, PhD, RN, FAAN, LaSalle UniversitySharon Bradley, RN, CICSchool of Nursing and Health SciencesJames Davis, MSN, RN, CCRN, CICDeborah Dubeck, RN, MPHACKNOWLEDGMENTSMichelle Feil, MSN, RN, CPPSThese individuals reviewed articles for Vol. 13, No. 1:Edward Finley, BSTerry Baldridge, PBT (ASCP), Nazareth HospitalLea Anne Gardner, PhD, RNLester Cash, MBA, BSM, RRT, Reading HospitalMichael J. Gaunt, PharmDValerie Cotter, DrNP, CRNP, FAANP, University ofMatthew Grissinger, RPh, FISMP, FASCPPennsylvania School of NursingMary C. Magee, MSN, RN, CPHQ, CPPSVincent Cowell, MD, Temple UniversityChristina Michalek, BSc Pharm, RPhJean Harpel, MSN, RN, CCRN, GCNS BC, ECRI InstituteSusan C. Wallace, MPH, CPHRMCollette Bishop Hendler, RN, MS, CICAdvisorsMary Hofmann, MD, Abington Hospital—Jefferson HealthMichael Cohen, RPh, MS, ScD, President, ISMPThomas Lamphere, BS, RRT-ACCS, RPFT, FAARC,Ronni Solomon, JD, Executive Vice PresidentPennsylvania Society for Respiratory Careand General Counsel, ECRI InstituteBette Mariani, PhD, RN, Villanova University CollegeAllen Vaida, PharmD, Executive Vice President, ISMPof NursingPatrick J. McDonnell, PharmD, Temple University SchoolProduction Staffof PharmacyJesse Munn, MBA, Managing EditorFrancine Miranda, RN, BSN, FASHRM, Lehigh ValleyJulia Barndt, MAHospitalEloise DeHaan, ELSMark Paules, RRT, Grand View HospitalSusan LaffertyChristopher M. Pezzi, MD, FACS, Abington Hospital—John Hall, Manager, Printing ServicesJefferson HealthTara Kolb, BFA, Manager, Media ServicesFrank Salvatore, RRT, MBA, FAARC, American AssociationKristin Finger, BSfor Respiratory CareSuzanne R. GehrisKaren Stark, RN, BSN, Jennersville Regional HospitalMarlene P. HartzellPam TripaldiBenjamin Pauldine, MSPennsylvania Patient Safety AdvisoryVol. 13, No. 1—March 2016 2016 Pennsylvania Patient Safety Authority
R E V I E W S & A N A LY S E SFamily Members Advocate for Improved Identificationof Patients with Dementia in the Acute Care SettingMichelle Feil, MSN, RN, CPPSSenior Patient Safety AnalystPennsylvania Patient Safety AuthorityABSTRACTA family member of a patient withdementia contacted the PennsylvaniaPatient Safety Authority and describedseveral “near miss” patient safetyevents in which hospital staff obtainedinaccurate information from the patient,unaware of the patient’s dementiadiagnosis. Healthcare facilities reported3,710 events through the PennsylvaniaPatient Safety Reporting System betweenJanuary 2005 and December 2014involving patients with dementia orpotentially unrecognized dementia.Analysts reviewing these reports found63 similar events in which hospitalstaff obtained inaccurate informationor consent from these patients. Fivefailure modes were identified: (1) failure to recognize preexisting dementia;(2) failure to assess competence anddecision-making capacity of patientswith dementia; (3) failure to identify areliable historian or surrogate decisionmaker for patients with dementia;(4) failure to contact a reliable historian or surrogate decision maker wheninformation or consent was requiredfor care; and (5) failure to communicate the patient’s dementia diagnosis,competence, and decision-makingcapacity with all members of the healthcare team. Risk reduction strategiestargeting these failure modes includescreening for dementia, assessingcapacity, identifying and communicating with surrogate decision makers,and standardizing communication ofa patient’s dementia diagnosis with allhospital staff. (Pa Patient Saf Advis 2016Mar;13[1]:1-10.)INTRODUCTIONPam Tripaldi’s father received a diagnosis of Alzheimer disease in 2007. Tripaldi servedas her father’s primary caregiver for the final four years of his life, during which hereceived care at several different hospitals. During these hospitalizations, she encountered near-miss patient safety events in which staff did not recognize her father’sdementia. Tripaldi contacted the Pennsylvania Patient Safety Authority in 2015 andrecounted examples of situations in which hospital staff either obtained inaccurateinformation from her father or failed to provide the assistance necessary to support herfather in activities of daily living, such as feeding himself.Tripaldi said, “If you asked my dad his name and date of birth—sure, he knew that. Butthey would ask him things like ‘Have you had surgery?’ and he would say no. Well yeshe did, he had quadruple bypass surgery!” She also described situations in which herfather did not get out of bed or did not eat, because the staff asked him if he wantedto or if he needed assistance and he would say no. “And sometimes I just couldn’t beupset with the staff, because I am not sure what information they were privy to becauseof HIPAA [Health Insurance Portability and Accountability Act].”*In looking for solutions to this problem, Tripaldi considered colored wristbands. “Hewore a wristband for fall risk and another one for allergies.” Tripaldi asked, “Couldn’the wear a wristband so that everyone would know that he had dementia?” Tripaldiblogs about this experience, communicates with other patients and family members with similar hospital experiences, and works with a chapter of the Alzheimer’sAssociation to raise awareness about the issue. Initially, she proposed using a purplewristband to identify patients with dementia, because that is the color for Alzheimerdisease. After discovering that purple is the color used to indicate DNR (i.e., donot resuscitate), Tripaldi began to advocate for use of a black wristband because,“Alzheimer’s is a disease that is dark, fearful and lonely to the patient, family membersand caregivers. It also brings to mind the POW and MIA flag, which like our lovedones, are lost but never forgotten.”In response to this inquiry, Authority analysts queried the Authority’s PennsylvaniaPatient Safety Reporting System (PA-PSRS) database for reports of events similar tothose described by Tripaldi to determine what events had been reported for patientswith dementia. Analysts were particularly interested to learn whether any reports mentioned use of colored wristbands to communicate a diagnosis of dementia, becausethe Authority has written about the risks involved in using colored wristbands to communicate clinical information, other than patient identification, and has suggested thathospitals limit the number and standardize the meanings of specific colors used forpatient wristbands.1-2 The Authority has also warned of potential risk associated withthe use of colored community wristbands (e.g., yellow Livestrong bracelets) not sanctioned for hospital use.3Authority analysis of events revealed similar instances in which inaccurate information or consent was obtained from patients with dementia or potentially unrecognizeddementia. Risk reduction strategies were identified through a review of the literature* The HIPAA Privacy Rule can be misinterpreted as prohibiting the communication of patient medicalinformation between healthcare providers and hospital staff. The rule allows for disclosure of this information for treatment purposes, and requires that hospitals develop policies to identify staff that requireaccess to this information and the minimum amount necessary to carry out their job duties and providecare to the patient. For more information please see Vol. 13, No. 1—March 2016 2016 Pennsylvania Patient Safety AuthorityPennsylvania Patient Safety AdvisoryPage 1
R E V I E W S & A N A LY S E Sand dementia care guidelines. Other ideasto improve patient identification weregathered from interviewing hospital staff,family members of patients with dementia, and dementia advocacy groups.BackgroundDementia is a neurocognitive disordercharacterized by an insidious onset andgradual decline in cognitive function thatresults in an inability to carry out activities of daily living independently. Multiplecauses for dementia exist; the most prevalent form is Alzheimer disease, whichcomprises 60% to 80% of cases.4 See“Recognizing Dementia and DementiaDue to Alzheimer Disease.”The prevalence of dementia increases withage, with estimates ranging from 1% to2% of adults at age 65 up to a high of 30%by age 85.4 The Alzheimer’s Associationestimates that 270,000 adults age 65 orolder received a diagnosis of Alzheimerdisease alone in Pennsylvania in 2015, andthere will be 320,000 by 2025. Nationallythis number was 5.1 million in 2015 andis expected to increase to 7.1 million by2025. Because of the large number ofaging baby boomers and extended lifeexpectancy of the general population, thisnumber is predicted to reach 13.8 millionby 2050.5Despite increasing prevalence of dementia, many individuals with this conditiondo not have a documented diagnosis.In fact, investigators estimate that physicians fail to recognize dementia in 19%to 67% of patients in the outpatientsetting—particularly in patients in earlierstages of disease with milder forms ofcognitive impairment.6-7 In these patients,cognitive deficits may not be detected, orwhen they are, they are incorrectly attributed to normal aging8-9 or mild cognitiveimpairment.10Deficits in the cognitive domains of memory and learning (present in all cases ofpossible or probable Alzheimer disease),Page 2RECOGNIZING DEMENTIA AND DEMENTIA DUE TOALZHEIMER DISEASEAccording to the American Psychiatric Association, the following criteria must bepresent to establish a diagnosis of dementia (i.e., major neurocognitive disorder)and dementia due to Alzheimer disease.Dementia—Significant deficits are identified in one or more of the following cognitivedomains: complex attention, executive function, language, memory and learning, perceptual-motor skills, or social cognition.—Cognitive deficits impair the individual’s ability to carry out everyday activitiesindependently (e.g., paying bills, managing medications).—These deficits are not attributable solely to delirium or better explained byanother mental disorder.Dementia due to Alzheimer disease—Criteria for dementia are met AND an Alzheimer disease genetic mutation isidentified from family history or genetic testing.—Cognitive decline occurs slowly over time, with deficits seen in memory andlearning and at least one other cognitive domain.—Cognitive function declines steadily over time, without extended plateaus.—These cognitive deficits are not better explained by other physiologic or psychiatric causes (e.g., cerebrovascular disease, substance abuse, other mentaldisorders).Source: Neurocognitive disorders. In: American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington (VA): American Psychiatric Publishing;2013:591-643.language, and complex attention candirectly impede an individual’s ability torecall, communicate, or understand information necessary to participate in medicaldecision-making, especially in later stagesof dementia.11-12 For these reasons, it isimportant to obtain information froma family member or other reliable informant when assessing or treating a patientwith dementia.13-14A diagnosis of dementia does not preclude a patient from actively participatingin his or her own decision making andcare; many are able to express values andpreferences relevant to medical decisions.However, with advanced dementia, a shiftto shared decision making (i.e., involvingthe patient and a family member or otherPennsylvania Patient Safety Advisorysurrogate), and ultimately delegated decision making (i.e., reliance on a surrogatedecision maker) becomes necessary.11-12METHODSPennsylvania Patient Safety Authorityanalysts identified events involvingpatients with dementia by querying theAuthority’s PA-PSRS database for eventscontaining the terms “dement” and“Alzheimer” (including misspellings)that were reported over a 10-year period,from January 2005 through December2014. Analysts also queried the PA-PSRSdatabase for events reported for patientsage 65 or older that contained the term“poor historian” to identify events involving patients with possibly unrecognizedVol. 13, No. 1—March 2016 2016 Pennsylvania Patient Safety Authority
dementia. Together, these reports constituted a dataset of events involving patientswith dementia or potentially unrecognized dementia that was used for furtheranalysis.First, analysts categorized reports usingPA-PSRS event type and harm score.Then, analysts queried the dataset forreports containing the keywords “historian,” “wrong,” “said,” “aware,” “consent,”“didn’t,” and “know” to find examplesof events similar to those described byTripaldi (i.e., events in which hospitalstaff obtained inaccurate or incompleteinformation, or consent, from patientswith dementia or potentially unrecognized dementia). Analysts then conductedan iterative thematic analysis of eventreport narratives to identify failure modesdescribed in this subset of similar events.Further, analysts queried the dataset ofevents involving patients with dementia orpotentially unrecognized dementia usingthe terms “band” (as in “wristband”),“gown,” “sign,” and “notify” to find eventreports that may have described a methodto identify patients with dementia.RESULTSAccording to the query of PA-PSRS,Pennsylvania healthcare facilities reported3,710 events involving patients withdementia or potentially unrecognizeddementia, including 96 reports forpatients age 65 or older, that containedthe term “poor historian” without mention of dementia or Alzheimer disease.Event Type and Harm ScoreFalls were the most frequently reportedevent type (n 1,710, 46.1%), followed byimpaired skin integrity (n 958, 25.8%).The majority of events were reportedas Incidents without harm to patients(n 3,194, 86.1%).Keywords, Similar Events, andFailure ModesAnalysts identified 627 event reportsthat contained the keywords “historian,”“wrong,” “said,” “aware,” “consent,”“didn’t,” and “know.” Of these, 63 eventreport narratives described events similarto those described by Tripaldi; the majority were reported as errors related toprocedures, treatments, or tests (n 47).Five failure modes were identified throughiterative thematic analysis of these63 event report narratives (see Figure).PA-PSRS EventsThe following is an example of a patientsafety event in which inaccurate information and informed consent was obtainedfrom a patient who was not initially recognized as having dementia by members ofthe healthcare team.*A [male older than 80 years] identified himself and stated that he wasto get injections in his left lower backfor left low back and leg pain. Thesurgical consent signed by the patientstated right low back, as well aspaperwork in his chart. I notified thesurgical resident who then changedthe consent to the left side. Uponentrance to the operating room, Iinformed the attending surgeon ofthis situation and he said that thepatient has dementia and his sonsigns his paperwork. The surgicalresident called the patient’s physicianto clarify, then returned to say thatwe would be now doing the patient’sright side.The following two reports describeinstances in which informed consent wasobtained from patients with an established diagnosis of dementia, without theinput of family members.* The details of the PA-PSRS event narrativesin this article have been modified to preserveconfidentiality.Vol. 13, No. 1—March 2016 2016 Pennsylvania Patient Safety AuthorityPennsylvania Patient Safety AdvisoryWhen reviewing the chart of a [maleolder than 75 years] before doing asurgical procedure, I discovered thatthere was no consent. My managerscalled the unit and the consent wassent down to them from the floor.The patient was on contact isolationprecautions, so I was unable to leavethe room to look at the consent. Mymanagers called into the room to saythat it was okay to proceed. After thecase ended I looked at the consentand found that it had been “signed”by the patient who has Parkinson’sand dementia and was not veryresponsive. His signature looked likea scribbled line on the paper. Theconsent was not signed by next of kinor any person capable of giving consent for the procedure.A [female older than 90 years] witha history of dementia was scheduledfor an interventional radiology (IR)procedure. The family left to getsomething to eat and returned tofind the patient had been sent downto IR. The nurse taking care ofpatient called IR to report that theconsent for the procedure had notyet been signed and was told thatconsent would be obtained in theirdepartment. The nurse was told thatthe patient needed to be sent downbecause the physician was there andready to proceed. The family returnedand was very upset. IR was calledand told to stop until the family couldcome down. The consent was signedby the son. The family spoke with apatient representative about this nearmiss and concern about confusedpatients signing consents.The following report describes an event inwhich information was obtained from apatient older than the age of 80 who wasnoted to be a “poor historian” but doesnot mention a diagnosis of dementia orAlzheimer disease. Though reported as anIncident without harm to the patient, thisevent involved a surgical procedure thatPage 3
R E V I E W S & A N A LY S E SFigure. The Sequence of Failure Modes In Events Involving Patients with Dementia(N 63), Reported to the Pennsylvania Patient Safety Authority, 2005 through 2014did not proceed as expected becauseof inaccurate information provided bythe patient.Failure to recognizepreexisting dementia(n 4)A [male older than 80 years] is apoor historian who denied havinghardware in his leg prior to surgery.During surgery to amputate the leg,the surgeon encountered an intramedullary rod. Orthopedic surgerywas consulted and an x-ray was doneto see the extent of the rod. Underthe supervision of the orthopedicsurgeon, the attending surgeon cutthe rod. The surgery was completedwithout further incident.Lack of Methods to IdentifyPatients with DementiaFailure to assesscompetence anddecision-makingcapacity (n 25)Two hundred fifty-two event reports forpatients with dementia or potentiallyunrecognized dementia (N 3,710)described the use of colored wristbandsto communicate fall risk. Five describedusing fall-risk signs, and three describedusing colored wristbands or gowns tocommunicate risk for wandering orelopement. Although cognitive impairment contributes risk for each of theseevents, no reports described the use ofthese methods to identify patients withdementia or other cognitive impairment,independent of these indications.Failure to identify areliable historianor surrogate decisionmaker (n 22)DISCUSSIONFailure to contact areliable historian orsurrogate decisionmaker (n 47)MS16087Failure to communicate a patient’sdementia diagnosis, competence,and decision-making capacity (n 6)Events reported through PA-PSRS suggestthat failing to communicate a patient’sdementia diagnosis to all members ofthe healthcare team is a valid concern inPennsylvania hospitals. However, it is onlyone of the aforementioned five failuremodes (see Figure), all of which are worthy of attention.Note: Illustrated modes categorize 63 events in which hospital staff obtained inaccurate or incomplete information or consent from patients with dementia or potentiallyunrecognized dementia. Failure mode total exceeds event total because some eventsinvolved multiple failure modes.Page 4Pennsylvania Patient Safety AdvisoryFailure to Recognize PreexistingDementiaPA-PSRS event reports describe situationsin which members of the healthcare teamfailed to recognize that a patient haddementia. Factors that may contributeVol. 13, No. 1—March 2016 2016 Pennsylvania Patient Safety Authority
to a missed diagnosis of dementia includethe following:Cognitive aging. Some cognitive changesare to be expected with normal aging.These changes are associated with structural and functional changes in the brainthat occur over a person’s lifetime. Thetypes and rates of these cognitive changesare influenced by a multitude of factors(e.g., genetics, educational level, healthstatus) and vary widely among individuals.8-9 In general, as people age, gradualdeclines occur across all domains of cognitive functioning, and steeper declinesare seen with advanced age. As a result,cognitive declines can be expected inthe majority of the oldest members ofsociety.15-16Mild cognitive impairment is an interim clinicaldiagnosis that bridges the gap betweencognitive aging and dementia.17 It is diagnosed when a person’s cognitive functionis impaired beyond what would normallybe expected for their age and educationallevel, but this impairment does not interfere with instrumental activities of dailyliving. Once the ability to carry out theseactivities independently is impaired, criteria for dementia are met. People with mildcognitive impairment are at high risk fordeveloping subsequent dementia.4,10,15Mild cognitive impairment.Education level and cognitive reserve.When asked why she thought hospitalstaff did not recognize her father as having dementia, Tripaldi said, “My fatherwas a brillian
Harold S. Kaplan, MD, Mount Sinai School of Medicine Michael L. Kay, MD, Wills Eye Hospital, Thomas Jefferson University Hospital, Pennsylvania Hospital John J. Kelly, MD, FACP, Abington Hospital—Jefferson Health Curtis P. Langlotz, MD, PhD, University of Pennsylvania Michael Leonard, MD
may be substantially higher (James, 2013, JPS) Crossing the Quality Chasm: A New Health System . National Patient Safety Goals IHI’s 100K lives Campaign 2004 2005 Patient Safety . Patient Quality & Safety Movement: Worldwide 2000 An Organization with a Memory NHS forms National Patient Safety Agency 2001 NPSF’s launches Patient Safety .
Cape Fear Valley has a Performance Improvement (PI)/ Patient Safety Plan. The plan describes the structures and functions of the Patient Safety Program and defines the responsibilities necessary to assure that the Patient Safety Program is effective. It can be found on the InfoWeb under: - 2012-2013 Performance Improvement/Patient Safety Plan
This Patient Safety Primer discusses the role of organizational leadership in improving patient safety. The crucial roles that frontline and midlevel providers play in improving safety are discussed in the related Safety Culture and High Reliability Patient Safety Primers. Institute for Healthcare Improvement Web site, Publications page.
Pennsylvania Forest Stewardship Program Identifying Pennsylvania Trees Objective for this presentation: To help individuals learn to identify common Pennsylvania trees using the Summer Key to Pennsylvania Trees (free copies available fro
The Honorable Bruce R. Beemer, Pennsylvania Attorney General Mark Bergstrom, Executive Director, Pennsylvania Commission on Sentencing Tyree Blocker, Commissioner, Pennsylvania State Police . Leo Dunn, Chairman, Pennsylvania Board of Probation and Parole Sarah E. Galbally, Secretary of Policy and Planning, Governor’s Office .
Pennsylvania Public Utility Commission before the Pennsylvania House Consumer Affairs Committee September 25,20 12 PENNSYLVANIA Pennsylvania Public Utility Commission 400 North Street Harrisburg, Pennsylvania 1 7 120 Telephone (717) 787-4301 httr,:/iwww.puc.state.pa.us
Reporting to the Behavioral Health Advisory Board The Advisory Board provides input to the administration of the Mental Health Plan and functions in an advisory capacity. The Advisory Board is involved in the Quality Improvement Committee by appointing an Advisory Board member to the QIC. In addition, there is a direct reporting link to each of .
D 341CS ASTM standards viscosity temperature charts for liquid petroleum D 412 Ringcutter, vacuum holding plate, ring tension test fixture (5 drawings) D 422 Air-jet dispersion cup for grain-size analysis of soil (1 drawing) D 429 Specimen holding fixture-adhesion of vulcanized rubber to metal (2 drawings) D 610A SSPC-VIS2/Colored Visual Examples D 623 Anvils for Goodrich flexometer (2 .
