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Pennsylvania Patient Safety Authority Releases March Advisory

Reports Show Patients Whose Medical Conditions Are Not Detected Prior to Surgery in an ASF are at Increased Risk for Complications After Surgery that Require Hospitalization

HARRISBURG, Pa., March 31 /PRNewswire-USNewswire/ -- Patients who are not screened or assessed properly prior to surgery in an ambulatory surgical facility (ASF) are at increased risk for complications after surgery that require hospitalization, according to data released in the 2009 March Pennsylvania Patient Safety Advisory.

Of the 467 reports submitted to the Pennsylvania Patient Safety Authority between June 2004 and December 2008, 203 (43%) are Serious Events or events that caused harm to the patient and most often required the patient to be transferred to a hospital. Half the total reports (234) involved an older patient (over age 65) and 23 reports (5%) involved a child.

"Our data shows many ambulatory surgical facilities need to improve their screening and assessment processes prior to accepting patients for surgery. Of the total reports, one hundred and twenty-four or twenty-seven percent show a need for an improved process in their facilities," Mike Doering, executive director of the Pennsylvania Patient Safety Authority said. "Patients can help by making sure they tell their healthcare provider about any existing conditions they have, including heart or respiratory conditions, that would increase their risk of complications."

Additionally, Doering said patients who know or suspect they have medical conditions such as obstructive sleep apnea (OSA), cardiovascular disease, hyperactive reactive airway disease, obesity or end-stage renal disease need to let their healthcare provider know prior to surgery to help avoid an unfavorable outcome. He added that sometimes the patient does not know. For example, OSA is undiagnosed in an estimated 80 percent of affected patients.

The Authority offers consumers patient safety tips for detecting OSA and tips on how they can communicate better with their healthcare provider prior to surgery.

Facilities can obtain risk reduction strategies through the Pennsylvania Patient Safety Advisory that include preoperative screening tools.

"The Authority has gathered guidance for facilities that is believed to work," Doering said. "One preoperative screening tool was obtained because our Patient Safety Liaison in the Northeast discovered it on a visit with the facility's Patient Safety Officer. The PSL program has provided us with feedback that enables us to help other facilities by sharing the information."

The Patient Safety Liaison program, begun as a pilot program late last year, is led by the Director of Educational Programs and serves facilities by sharing educational resources developed by the Authority and obtaining feedback that allows the Authority to provide support to facilities for future patient safety initiatives.

For more information about the PSL program or the data received from ambulatory surgical facilities go to the 2009 March Pennsylvania Patient Safety Advisory at

The Authority's quarterly March 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:

  • Incorrect Patient Weights Lead to Medication Errors: Nearly 480 reports submitted to the Authority specifically note that medication errors occurred from breakdowns during the process of obtaining, documenting and/or communicating patient weights. Analysis shows that 67 % of the events reached the patient. The most frequent area for the error was in the Emergency Department. Strategies to address these problems are outlined in this article, including providing all units with the necessary equipment to weigh patients.
  • Risks Associated with Patient Transport from One Care Area to Another: Reports show non-ICU (intensive care) patients are at risk in the hospital when they are transferred from one care area to another by unlicensed hospital personnel. In 2,390 patient transport reports, facilities have identified Serious Events and Incidents occurring due to problems with communication, intravenous lines, monitoring and other issues. This article examines risk reduction strategies to ensure the safe intra-hospital transport of the patient from one care area to another.
  • MR Screening Practices Questioned: Some patients with implanted pacemakers or other metal objects are not being screened properly prior to receiving an MRI (magnetic resonance image) according to about 150 reports submitted to the Authority. The data shows the MR (magnetic resonance) clinical screening process was inadequate, and in some cases, patients were permitted with implanted pacemakers (46%) and other metal objects to enter the MRI scanner room. This article provides facilities with guidance on developing rigorous screening practices to help reduce the hazards from implanted and other ferromagnetic objects. The Authority also offers consumer tips for patients to avoid an unfavorable outcome when an MRI scan is needed.
  • Strategies to Reduce MRSA Infection Rates: About 70 percent of healthcare-associated infections (HAIs) in the United States are caused by antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA). Several U.S. facilities have significantly reduced rates of MRSA transmission and associated infections. This article describes successful efforts made in Pennsylvania's healthcare facilities to reduce MRSA through system improvement approaches.
  • Wrong-Site Surgery Quarterly Update: This article provides an update on events of wrong-site surgery in Pennsylvania. Encouraging signs are emerging from recent data obtained through a regional collaborative between the Authority and the Health Care Improvement Foundation's Partnership for Patient Care Wrong-Site Surgery Prevention Program. A time-out script competition is underway with five entries and open comment on the Authority's website. Also available are patient safety tools for preventing wrong-site surgery. Consumer tips for preventing wrong-site surgery are also available.

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

SOURCE Pennsylvania Patient Safety Authority
Copyright©2009 PR Newswire.
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