Pennsylvania Patient Safety Authority Releases Septembe...(changes that require constant cardiac mo...),Health

Date:9/16/2009

changes that require constant cardiac monitoring or transfers to a higher level of care, for which treatment may be delayed due to bed unavailability. Many facilities implement remote cardiac monitoring in remote locations to facilitate alarm notification, which alerts healthcare providers about any change in a patient's condition. However, 74% of the 194 Serious Events and Incidents reported to the Authority from June 2004 to December 2008 associated with remote cardiac monitoring were issues with communication and monitoring problems. This article discusses the problems in detail and gives risk reduction strategies facilities can implement to avoid further events.

Problems with Drainage Tubes: Epidural or subarachnoid catheters (also called lumbar drainage catheters) are very small hollow tubes inserted into patients to administer medications or drain body fluids. Under certain conditions, they can shear, leaving a fragment in the patient. Between June 2004 and December 2008, the Authority received 13 reports related to epidural or subarachnoid catheter shear. Predominant causes of the catheter shear include applying excessive force while removing the catheter and withdrawing the catheter back through the needle. Other causes are listed in this article along with prevention strategies.

Errors in Radiation Therapy: Radiation therapy is a highly regulated medical practice with historically low error and injury rates. Rare instances of radiation therapy errors resulting in severe injuries (e.g., vital organs) have been documented. This article emphasizes that understanding the technology and therapy is vital to preventing errors, as well as following established practices.

Barriers to Urinary Catheter Insertion and Management Practices: Despite evidence that catheter-associated urinary tract infections (CAUTIs) and accompanying adverse outcomes can often be prevented; these infections remain among the most predominant health
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SOURCE Pennsylvania Patient Safety Authority Copyright©2009 PR Newswire. All rights reserved

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