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Pennsylvania Patient Safety Authority Releases June Advisory

Two Facilities in Pennsylvania Make Substantial Progress in Reducing Infections for Patients in Intensive Care

HARRISBURG, Pa., June 30 /PRNewswire-USNewswire/ -- Two hospitals in southeast Pennsylvania have successfully reduced or eliminated healthcare-associated infections (HAIs) for intensive care patients in their facilities and are featured in the Pennsylvania Patient Safety Authority's 2009 June Patient Safety Advisory.

Patients in intensive care are at high risk for HAIs due to their serious illness and weakened immune systems. Ventilator-associated pneumonia (VAP) is healthcare-associated pneumonia in a patient who must use a machine or other device for more than 48 hours in order to breathe.

Roxborough Memorial Hospital and St. Christopher's Hospital for Children, both in Philadelphia, have implemented proven risk reduction strategies (known as bundles) to prevent VAP in their patients. As a result of team effort, Roxborough reduced VAP in its facility from 12 events in 2004 to two in 2006. From November 2006 through June 2008 there were zero cases of VAP at Roxborough. In July 2008, one case was reported. A patient was on a break from being sedated and subsequently took out his breathing tube which caused him to suck food or liquid into his lungs. This action caused an infection in the lungs known as aspiration pneumonia.

"In 2005, Roxborough began collecting specific data related to devices and implemented protocols recommended by the Institute for Healthcare Improvement during its [100,000 lives] campaign to reduce medical errors," Mike Doering, executive director of the Pennsylvania Patient Safety Authority said. "Due to their efforts, Roxborough staff nearly eliminated ventilator-associated pneumonia in their facility. Their success shows what facilities can achieve if staff works together in making zero their target number for infections."

St. Christopher's Hospital for Children discovered in 2006 that its VAP rate in its neonatal intensive care unit (NICU) was higher for particular birth weights than the national average. At the time of the discovery, guidance and protocols (bundles) for reducing ventilator-associated pneumonia in adults were common; however information for reducing VAP in newborns was not readily available. St. Christopher's studied the issue, organized a team of professionals on the subject and revised existing pediatric protocols to serve its newborn population.

"St. Christopher's recognized a problem in their facility and took action to solve it, even if it meant redeveloping existing guidance to fit their facility's needs," Doering said. "Once the revised VAP bundles were implemented, St. Christopher's saw a sixty percent decrease in VAP for its newborns. That number decreased again the following year to one case as a result of their efforts."

Doering attributed the hospitals' common approaches of developing multi-disciplinary teams to help develop and implement the bundles as key to their success. He hopes that other facilities in the state learn from example and develop their own multi-disciplinary teams to tackle not only infections but other outstanding events happening in Pennsylvania's healthcare facilities.

The Authority recently developed a Patient Safety Liaison program to help facilities identify problems and develop solutions. Currently, facilities in the northeast, northwest and south central regions of Pennsylvania have liaisons. Three other regions in Pennsylvania are expected to have their own liaison by the end of the year, which will ensure that all healthcare facilities reporting under Act 13 of 2002 and Act 30 of 2006 will have someone they can turn to from the Authority for patient safety information and assistance.

"So far, based on the interaction of the liaisons with the facilities, we've developed a MRSA infection seminar for ambulatory surgical facilities, a basic patient safety officer training program and have begun a hospital collaborative to reduce mix-ups of phlebotomy lab specimens," Doering said. "I expect the feedback to increase as facilities get used to having us around and additional liaisons are put in place. We're here to help facilities find the information they need to develop and implement successful programs like the VAP programs at Roxborough and St. Christopher's."

"There's so much information out there that facilities most likely don't have to reinvent the wheel, but simply tailor the success of others to meet their facility's needs," Doering added.

For more information about the VAP programs at Roxborough or St. Christopher's Hospital for Children go to the 2009 June Pennsylvania Patient Safety Advisory at

The Authority's quarterly 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:

  • Preventing Retention of Foreign Objects (RFOs) in a Patient: Leaving objects inside of a patient after surgery can often lead to serious injury. In 2008, the Authority received 2,228 reports involving an incorrect sponge, sharp or instrument count. Of the reports, 1,040 (47%) involved incorrect needle counts, 731 (33%) involved incorrect equipment counts, and 454 (20%) involved incorrect sponge counts. During that same one-year period the Authority received 194 reports of RFOs reported as a separate event category. Of those reports, 160 (84%) indicate that a radiograph was done. In 43 (22%) reports, the RFO was discovered after the patient left the operating room. Surgical counts are intended to prevent the retention of a sponge, sharp or instrument during a surgical procedure, yet despite the methodical process, patients are still having items left inside of them after a procedure. This article details the processes of surgical counts and gives guidance for prevention of RFOs.
  • Medication Errors Occurring in the Radiologic Services Department: Nearly 1,000 event reports submitted to the Authority specifically mentioned medication errors that occurred in care areas providing radiologic services. This article explores the issue of medication errors in radiology with some surprising results. Risk reduction strategies are also given to prevent medication errors. Consumer tips are also available with information for patients on how they can protect themselves from medication errors.
  • Complications Related to Gynecologic Procedures: The Authority has received 376 reports of complications that occur during certain gynecologic procedures. The most commonly reported event is the puncture of organs (77%), most frequently the uterus (96%). This article details the information found in the data and gives risk reduction strategies for prevention.
  • Safety for Patients Receiving an MRI(magnetic resonance image): Objects becoming airborne in the MRI scan area can cause severe harm or even death to patients or others if these objects are not removed from the area prior to a magnetic resonance (MR) scan. Between June 2004 and December 2008 the Authority received 27 reports about magnetic objects becoming airborne in the MR environment, 16 magnetic items were brought into the MRI scanner room without becoming airborne and five magnetic items were almost allowed into the MRI scanner room. Proper techniques for scanning patients for magnetic items are discussed and protocols for identifying and labeling equipment that can and cannot be brought into the scanner room are also detailed in this article. Consumer tips are also available for patients to protect themselves prior to an MR scan.
  • Wrong-Site Surgery Quarterly Update: This article provides an update of encouraging trends the Authority is beginning to see in regard to preventing wrong-site surgeries. The southeastern Pennsylvania regional collaborative to prevent wrong-site surgery that began in March 2008 with 30 facilities has seen wrong-site procedures and wrong-site anesthetic blocks reduced or eliminated for a three-month period of time. More reports of wrong-site surgeries are also highlighted in this article with comments for how facilities can improve. Consumer tips are also available for patients and families to help prevent wrong-site surgeries. The Authority will continue to provide updates of its efforts to prevent wrong-site surgery in Pennsylvania.

For a copy of the 2009 June Pennsylvania Patient Safety Advisory or more information on the Pennsylvania Patient Safety Authority, visit the Authority's website at

SOURCE Pennsylvania Patient Safety Authority
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