MHA https://www.mnhospitals.org RSS feeds for MHA 60 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2154/minnesota-patient-safety-alert-controlled-substance-diversion-can-lead-to-health-care-associated-infection#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2154 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2154&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Controlled substance diversion can lead to health care-associated infection https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2154/minnesota-patient-safety-alert-controlled-substance-diversion-can-lead-to-health-care-associated-infection This safety alert is issued to encourage continued implementation of the recommendations to prevent and report drug diversion and also to highlight specific actions required to prevent and respond to the threat of health care–associated infections resulting from drug diversion by health care personnel.  Background The Controlled Substance Diversion Coalition, convened in 2011-2012 by the Minnesota Department of Health and the Minnesota Hospital Association, was a broad-based stakeholder forum convened to identify and share strategies to increase awareness of and prevent controlled substance diversion within hospitals. The coalition’s final report in March of 2012 included data from the U.S. Drug Enforcement Administration (DEA). There were 250 reports to the DEA of theft or loss of controlled substances attributable to health care personnel diversion from pharmacies within hospitals, clinics, and outpatient surgery centers in Minnesota from 2005 to 2011. And, the number of reports increased from 16 in 2006 to 52 in 2010, an increase of 325 percent.   New reports of theft or loss from 2011 – August 2013 Preliminary data of health care personnel diversion in pharmacies within hospitals, clinics, and outpatient surgery centers as reported to the DEA through August 2013 was shared with MDH. There were 65 reports in 2011 and 104 in 2012. The number of reports doubled from 2010 to 2012. For the first eight months of 2013 there were 69 reports which was on-pace to exceed 2012 numbers. Thirty-one percent of the medications diverted were intravenous or intramuscular medications. This percentage has remained relatively consistent over time.    The coalition anticipated that the number of reports would increase in subsequent years as a result of the coalition’s efforts to raise awareness of the problem of diversion and to implement requirements and recommendations.  Diversion of injectable medication represents a risk for transmission of blood borne pathogens (BBP) and for bacteremia. A recent review by the Centers for Disease Control and Prevention (CDC) identified six outbreaks of bacterial and hepatitis C virus (HCV) infections that resulted from drug diversion by health care personnel in U.S. health care settings in the past 10 years.  Recommendations As diversion of an injectable medication can represent a BBP transmission risk similar to other types of healthcare BBP exposures, review and update BBP exposure protocols and controlled substance diversion prevention policies to address issues specific to injectable medication diversion.  Immediate testing for BBP of the health care personnel suspected/confirmed of injectable medication diversion; Notification of patients at risk for BBP transmission due to injectable medication diversion and recommendations for follow-up of BBP testing. Contact the of Minnesota Department of Health Infectious Disease Division for consultation regarding BBP risk assessment to patients at 651-201-5414 or toll-free at 877-676-5414. Conduct a gap analysis with the Minnesota Controlled Substance Diversion Prevention roadmap. Develop action plan including law enforcement notification based on roadmap and tool kit. Review and comply with reporting requirements, now including mandatory reporting to licensing boards. In addition to previous reporting requirements, a newly-adopted law requires health care entities to report to a licensed professional’s licensing board when the entity has knowledge of a drug diversion by the licensed professional at their facility. References Melissa K. Schaefer, MD, Joseph F. Perz, DrPH, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, Outbreaks of Infections Associated With Drug Diversion by US Health Care Personnel. Published online: June 01, 2014.  Centers for Disease Control and Prevention Drug Diversion Website Minnesota Controlled Substance Diversion Prevention Coalition Final Report, March 2012. Wed, 23 Jul 2014 14:19:00 GMT f1397696-738c-4295-afcd-943feb885714:2154 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2155/minnesota-patient-safety-alert-mitigating-fall-injury-risks#Comments 11 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2155 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2155&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Mitigating Fall Injury Risks https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2155/minnesota-patient-safety-alert-mitigating-fall-injury-risks Background Although Minnesota hospitals have been working diligently to eliminate falls and injury from falls, last year Minnesota had an increase in falls resulting in serious injury and fall deaths and there is a concerning trend that could lead to a higher number of deaths related to falls this year. Review of the root cause information submitted in relation to these fall events indicate the following common factors: In 100% of fall death cases this year, the patients were at high-risk for injury from falls. In addition to having a system in place to identify and address an individual’s risk factors that put them at a higher risk for falls, MHA and MDH recommend facilities use the Fall Injury Reduction Protocol included in this alert as a guide to identify and mitigate modifiable risk factors that place patients at a higher risk of being injured if they do fall. In 67% of fall death cases this year, the patients were on anticoagulants and at risk for bleeding if a fall occurred. Interventions should be customized for patients with a coagulation risk factor that puts them at higher risk for injury, including the use of high/low beds, staying within arm’s reach, and educating patients and families about the increased risk of injury due to anticoagulation therapy. It was also noted that in 100% of the cases in which an alarm was in place, the alarm was ineffective in alerting the staff prior to the patient fall. Issues identified included: Patient took alarm off Alert not functioning properly Alarms were not reactivated Alarm not audible to nursing staff Alarm did not provide sufficient lead time to prevent patient from getting up on their own. MHA and MDH remind facilities that alarms alone are not a prevention strategy. If bed alarms are used, other redundancies need to be built in to the falls plan. Interventions should be customized to specific patient risks, including the use of high/low beds, floor mats, or staying within arm’s reach of patients when they are out of bed or the chair. If alarms are used, facilities should ensure they operate properly. MHA and MDH recommend that facilities revisit their fall and fall injury prevention policies and processes to address the issue of screening, assessing and linking appropriate interventions for patients with a coagulation fall injury risk factor. Recommendations your organization should consider in developing processes are reviewed in greater depth below. For more information on this alert, contact Julie Apold, MHA senior director of patient safety, at 651-641-1121 or toll-free at 800-462-5393; or Rachel Jokela, adverse health events program director, Division of Health Policy, MDH, 651-201-5807. Recommendations for Mitigating Fall Injury Risk for Patients on Coagulants These recommendations are intended to share best practices based on learnings from the adverse health event reporting system and statewide falls prevention activities involving Minnesota hospitals and ambulatory surgical centers. The recommendations are not intended to address all fall program related clinical and regulatory requirements. It is recommended that in addition to having a robust system in place to identify and address an individual patient’s risk factors that place them at a higher risk for falling (Appendix B), each organization should incorporate within this system a robust process for identifying and addressing each patient’s specific injury risk factors that place them at a higher risk for sustaining a serious injury if they do fall. A Fall Injury Reduction Protocol to identify and mitigate modifiable risk factors has been developed in consultation with the MHA Fall Advisory Work Group and Patricia Quigley, PhD, MPH, ARNP, FAAN, FAANP which provides a decision algorithm for identifying and mitigating specific fall injury risk factors (Appendix A). The algorithm is based on the ABCs fall injury risk factors: A = Age >85 B = Bones C = Coagulation S = Surgical (post-surgical patients) Although any of these risk factors places the patient at greater risk for sustaining a serious injury from a fall, 67% of the deaths associated with an inpatient fall this current year have occurred in patients with a coagulation risk factor. It is critical that interventions are customized for those patients identified at risk of injury from a fall according to their specific risk factors. Interventions that should be considered for patients with a coagulation risk factor include: Provide education to patients and families, which includes teach back, on why they are at a higher risk for serious injury if they do fall now that they are on blood thinners High/low beds Physical therapy consult to evaluate the patient’s mobility and patient’s physical environment for areas of injury risk Include environmental checks within regular patient rounds, e.g., checking clutter, eliminating or padding sharp edges, floor mats are in place and are being used appropriately to pad flooring “Staying within arm’s reach” (more information in Appendix C) If the patient has a traumatic brain injury, consider a helmet If the patient uses a wheelchair, place an anti-tipping device on chair Alarms alone are not a prevention strategy: If bed alarms are used, other redundancies need to be built in to the falls plan, such as those outlined above. If an alarm is used, strategies need to be in place to ensure that the appropriate alarm is used for the patient, the alarm is operating properly, is activated and is set at the appropriate sensitivity and volume level. A sample flow diagram for conducting a patient fall screening, fall and injury risk assessment, and linking interventions for identified specific fall and injury risks is outlined in the link below. More detailed algorithms for specific fall and injury risk factors are included in Appendix A (Fall Risk) and Appendix B (Injury Risk). See Sample Flow Diagram, and Algorithms for specific fall and injury risk factors. Wed, 17 Apr 2013 17:37:00 GMT f1397696-738c-4295-afcd-943feb885714:2155 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2159/minnesota-patient-safety-alert-accountability-for-objects-used-during-gynecological-procedures-performed-in-the-operating-room#Comments 7 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2159 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2159&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Accountability for objects used during gynecological procedures performed in the operating room https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2159/minnesota-patient-safety-alert-accountability-for-objects-used-during-gynecological-procedures-performed-in-the-operating-room Background The Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) reviewed data from the adverse health event reporting system and have identified a cluster of foreign objects being retained following gynecological (GYN) procedures performed in the operating room.    Since 2010, over a quarter (27%) of retained foreign objects have been related to GYN procedures performed in the operating room. The majority (40%) of the objects were retained following hysterectomy procedures; 20% were related to suburetheral sling procedures.    Vaginal packing was the most common (53%) item retained. Other items retained included: sponges; KOH ring instrument and balloon; plastic centering tab; and ultrasound transducer protective sleeve.    Findings from root cause analyses indicate that the most common (73%) reasons for the retention were issues related to communicating the presence of packed items to the next level of care and accounting for items being intact when removed or after use. Recommendation Packed Items MHA and MDH recommend that facilities revisit their policies and processes to address the issue of ensuring items that are used for packing are removed as intended, with special attention to packing used in GYN procedures. The following recommendations should be considered in developing processes within your organization: The physician/provider placing packed item communicates the presence of packed item(s) to the team when placed; Any item placed, and its location, is documented in a manner that it can be accounted for at the end of the case (e.g., note in patient’s chart, flag in EMR); There is a clear process for accounting for packed items at the end of the case; An order is written by the physician for packing removal, indicating when the packing should be removed; Order/instructions for removal includes: type and location of packed item(s) and instructions, including timing, if known, for removal; Orders/instructions for removal of packed items are made available to staff responsible for removal (e.g. readily accessible to staff in EMR); The presence of packed materials is communicated during hand-off to post-procedure staff; A standardized process and clear accountability is in place for removal of the item post- procedure. For example: A flag is placed in the medical record, visible across departments, that is present until the packing is removed; Person responsible for removal of packed item(s) removes the item(s)s and documents removal. Accounting for Items Being Intact MHA and MDH recommend that facilities revisit their surgical policies and processes to address the issue of ensuring objects used in procedures are intact. The following recommendations should be considered in developing processes within your organization: Responsibility is assigned to a specific team role for visualization of equipment/devices that will be used during the procedure to ensure the device and all of its components are intact prior to the procedure. Responsibility is assigned to a specific team role for visualization of equipment/devices and ensuring that the device is intact and all components are accounted for following the procedure. Before deployment of a new device or equipment, staff should be educated on all component parts of the object that could potentially be retained or may be at higher risk for breakage. Any breakage or separation of device components during a procedure, even if the object is not retained, should be tracked to identify potentially higher-risk devices or instruments for breakage. Tue, 24 Jul 2012 19:38:00 GMT f1397696-738c-4295-afcd-943feb885714:2159 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2174/retained-objects-in-gynecological-surgical-procedures-alert#Comments 7 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2174 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2174&PortalID=0&TabID=578 Retained Objects in Gynecological Surgical Procedures Alert https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2174/retained-objects-in-gynecological-surgical-procedures-alert Accounting for objects used during gynecological procedures performed in the operating room. Background The Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) reviewed data from the adverse health event reporting system and have identified a cluster of foreign objects being retained following gynecological (GYN) procedures performed in the operating room. Since 2010, over a quarter (27%) of retained foreign objects have been related to GYN procedures performed in the operating room. The majority (40%) of the objects were retained following hysterectomy procedures; 20% were related to suburetheral sling procedures. Vaginal packing was the most common (53%) item retained. Other items retained included: sponges; KOH ring instrument and balloon; plastic centering tab; and ultrasound transducer protective sleeve. Findings from root cause analyses indicate that the most common (73%) reasons for the retention were issues related to communicating the presence of packed items to the next level of care and accounting for items being intact when removed or after use. Recommendation Packed Items MHA and MDH recommend that facilities revisit their policies and processes to address the issue of ensuring items that are used for packing are removed as intended, with special attention to packing used in GYN procedures. The following recommendations should be considered in developing processes within your organization: The physician/provider placing packed item communicates the presence of packed item(s) to the team when placed; Any item placed, and its location, is documented in a manner that it can be accounted for at the end of the case (e.g., note in patient’s chart, flag in EMR); There is a clear process for accounting for packed items at the end of the case; An order is written by the physician for packing removal, indicating when the packing should be removed; Order/instructions for removal includes: type and location of packed item(s) and instructions, including timing, if known, for removal; Orders/instructions for removal of packed items are made available to staff responsible for removal (e.g. readily accessible to staff in EMR); The presence of packed materials is communicated during hand-off to post-procedure staff; A standardized process and clear accountability is in place for removal of the item post- procedure. For example: A flag is placed in the medical record, visible across departments, that is present until the packing is removed; Person responsible for removal of packed item(s) removes the item(s)s and documents removal. Accounting for Items Being Intact MHA and MDH recommend that facilities revisit their surgical policies and processes to address the issue of ensuring objects used in procedures are intact. The following recommendations should be considered in developing processes within your organization: Responsibility is assigned to a specific team role for visualization of equipment/devices that will be used during the procedure to ensure the device and all of its components are intact prior to the procedure. Responsibility is assigned to a specific team role for visualization of equipment/devices and ensuring that the device is intact and all components areaccounted for following the procedure. Before deployment of a new device or equipment, staff should be educated on all component parts of the object that could potentially be retained or may be at higher risk for breakage. Any breakage or separation of device components during a procedure, even if the object is not retained, should be tracked to identify potentially higher-risk devices or instruments for breakage. For more information on this alert, contact Julie Apold, MHA director of patient safety, 651- 641-1121 or toll-free at 800-462-5393 or Rachel Jokela, Adverse Health Events Program Director, Division of Health Policy, MN Department of Health, 651-201-5807. Tue, 24 Jul 2012 15:32:00 GMT f1397696-738c-4295-afcd-943feb885714:2174 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2173/implant-verification-alert#Comments 12 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2173 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2173&PortalID=0&TabID=578 Implant Verification Alert https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2173/implant-verification-alert Implant Verification Close to 40% of wrong surgeries/procedures reported under the Minnesota Adverse Event Reporting Law last year (Oct. 7, 2010 -Oct. 6, 2011) were related to wrong implants. Review of reported wrong procedure events involving implants indicated issues with verification of the correct implant at each step of the process including: Scheduling Requesting the implant(s) Pulling the implant(s) prior to case Team Briefing Pre-procedure verification Time Out Selecting implant(s) from case cart In January of 2007, a Minnesota Safety Alert was issued related to preventing wrong eye/wrong lens procedures. The Minnesota Department of Health and Minnesota Hospital Association have reviewed: 1) the root cause analyses from wrong procedure events occurring this past year involving implants; and 2) national and local best practices to develop a set of recommendations for implant verification. The recommendations include verifications steps for: Intraocular implants (IOL) Other implants — when implant is known prior to the case Other implants — when implant is not known prior to the case, e.g. hip or knee replacements. For more information on this alert, contact Julie Apold, MHA director of patient safety, 651- 641-1121 or toll-free at 800-462-5393 or Rachel Jokela, adverse health event program director, MN Department of Health,  651-201-5807. Fri, 11 May 2012 21:16:00 GMT f1397696-738c-4295-afcd-943feb885714:2173 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2162/minnesota-patient-safety-alert-implant-verification#Comments 46 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2162 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2162&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Implant Verification https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2162/minnesota-patient-safety-alert-implant-verification Background Close to 40% of wrong surgeries/procedures reported under the Minnesota Adverse Event Reporting Law last year (October 7, 2010-October 6, 2011) were related to wrong implants. Review of reported wrong procedure events involving implants indicated issues with verification of the correct implant at each step of the process including:  Scheduling Requesting the implant(s) Pulling the implant(s) prior to case Team Briefing Pre-procedure verification Time Out     Selecting implant(s) from case cart In January of 2007, a Minnesota Safety Alert was issued related to preventing wrong eye/wrong lens procedures: http://www.mnhospitals.org/inc/data/pdfs/Alert_Advisory_1-9-07.pdf. The Minnesota Department of Health and Minnesota Hospital Association have reviewed: 1) the root cause analyses from wrong procedure events occurring this past year involving implants; and 2) national and local best practices to develop a set of recommendations for implant verification. The recommendations include verifications steps for:  1.   Intraocular implants (IOL)  2.   Other implants — when implant is known prior to the case  3.   Other implants — when implant is not known prior to the case, e.g. hip or knee replacements. The resulting recommendations are outlined beginning on page two of this safety alert. Implant Verification Recommendations These recommendations are intended to provide guidance to improve the consistency of implant verification practices across Minnesota hospitals and ambulatory surgical centers and address issues identified through the reporting of wrong procedures related to incorrect implants. The recommendations are not intended to address all implant related clinical and regulatory requirements. Implants — Intraocular lens (IOL) Verification of correct intraocular lens placement (IOL) The facility has a process in place to require ordering providers to submit IOL requests in writing. IOL requests must be received prior to case prep, at minimum, for the case to proceed. IOL requests include, at a minimum, the following key IOL information: Date of surgery Patient  Surgeon  Right vs. Left Posterior vs. anterior Model # Diopter  If the facility does not receive a written IOL request prior to case prep (ideally received earlier in the process) with completed key IOL information, the case does not move forward.      If the surgeon selects the IOL for the case from the supply area, the written request including the key IOL information still needs to be completed by the surgeon prior to case prep. A process is in place to verify the correct lens at the following times, at minimum: Selection of IOL implants for case from supply area  Verification: Verify correct lens against source documents such as the implant request form, patient’s medical record, surgical notes. Pre-operative team briefing Verification: Verify implant is available for case. Time Out process Verification: Verify implant is available in the room for case. Opening the implant to the sterile field. Verification: 1) confirm the implant packaging against source documents, such as the implant request form; 2) read aloud the implant information from the packaging; and 3) show the packaging information to the surgeon. The source documents, such as the implant request form, and selected implant are kept together after selection of the IOL for the case. The facility requires that only one lens (per operative eye) per case is in the procedure room. If the surgeon requests more than one option, as soon as a decision is made on the correct lens for the case, the second lens is placed out of sight in a pre-designated area. Implants — If implant is known prior to procedure (non-IOL procedures) The facility has a process in place to require ordering providers to submit implant requests in writing. Implant requests include, at a minimum, the following key information: Date of surgery Patient o  Surgeon Implant and specifications the facility will need to order or pull the implant for the case Right vs. Left, if applicable For breast implants: Saline vs. Silicone If the facility does not receive a written implant request prior to case prep (ideally received earlier in the process) with completed key information, the case does not move forward.         A process is in place to verify the correct implant at the following times, at minimum: o   Selection of implants for case from supply area, if applicable §      Verification: Verify correct implant against source documents such as the implant request form, patient’s medical record, surgical notes. o   Pre-operative team briefing §      Verification: Verify implant is available for case. o   Time Out process §      Verification: Verify implant is available in room for case. o   Opening the implant to the sterile field. §      Verification: 1) confirm the implant packaging against source documents, such as the implant request form; 2) read aloud the implant information from the packaging, including laterality if applicable; and 3) show the packaging information to the surgeon. The facility requires that only the implant needed for the case is in the procedure room. If the surgeon requests more than one option, as soon as a decision is made on the correct implant for the case, additional implants are placed out of sight in a pre- designated area. The facility has developed an orientation for vendors involved in selecting implants for procedures which includes expectations for the vendor’s role in implant verification. The facility requires that vendors complete orientation prior to handling implants prior to, or during, a case. If a vendor selects the implant for the case, the implant is handed off to a member of the procedure team who completes verification of the implant against source documents. The vendor does not introduce the implant to the sterile field. Implants — If correct implant is not known prior to procedure (e.g., need to trial multiple knee components during procedure prior to final implant selection): The facility has a process in place to require ordering providers to submit implant requests in writing. Implant requests include, at a minimum, the following key information: Date of surgery Patient Surgeon o  Right vs. Left, if applicable Which implant options to have available If the facility does not receive a written implant request prior to case prep (ideally received earlier in the process) with completed key information, the case does not move forward. A process is in place to verify the correct implant at the following times, at minimum: Selection of implants for case from supply area, if applicable Verification: Verify correct implant against source documents such as the implant request form, patient’s medical record, surgical notes.  Pre-operative team briefing Verification: Verify implant is available for case. Time Out process Verification: Verify implant is available in room for case. Selection of implant from case cart, if applicable Verification: Verify correct implant against source documents such as the implant request form. Opening the implant to the sterile field. Verification: 1) confirm the implant packaging against source documents, such as the implant request form; 2) read aloud the implant information from the packaging, including laterality if applicable; and 3) show the packaging information to the surgeon. If cart is in procedure room with multiple implants, ideally only the cart with the correct side implants (L vs. R) is in the room. If carts are not able to be separated (L vs. R) due to storage or other issues, left and right components are clearly separated and labeled on the cart. The facility has developed an orientation for vendors involved in selecting implants for procedures which includes expectations for the vendor’s role in implant verification. The facility requires that vendors complete orientation prior to handling implants prior to, or during, a case. If a vendor selects the implant for the case, the implant is handed off to a member of the procedure team who completes verification of the implant against source documents. The vendor does not introduce the implant to the sterile field. Fri, 11 May 2012 16:05:00 GMT f1397696-738c-4295-afcd-943feb885714:2162 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2168/minnesota-patient-safety-alert-spine-level-localization#Comments 57 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2168 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2168&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Spine Level Localization https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2168/minnesota-patient-safety-alert-spine-level-localization Background Approximately 30 percent of wrong-site surgeries reported under the Minnesota Adverse Event Reporting Law are wrong level spine procedures. Review of reported wrong level spine procedures indicates that key localization issues include:  1)  There are issues that make placing the radiopaque instrument for intra-operative imaging prone to misinterpretation. These include: abnormal anatomy (segmentation anomalies, arthritic changes); specific placement and/or movement of the marker; and patient size limiting quality of imaging. 2)  The radiopaque instrument used to identify the current level for intra-operative imaging is often removed prior to placing a durable mark at that level resulting in the misinterpretation of the X-ray when it is available to be viewed in the room. In November 2010, a work group of Minnesota spine surgeons met to review the findings from reported events and to develop recommendations to address identified key issues associated with wrong level spine procedures. The resulting recommendations are outlined on page two of this safety alert. Spinal Level Localization Recommendation These recommendations are intended to provide guidance to improve the consistency of identifying spine levels for surgical procedures in Minnesota hospitals and to address issues identified through the reporting of wrong level spine procedures through the Minnesota Adverse Health Care Event Reporting Law. The recommendations are not intended to address all clinical and regulatory requirements related to surgical procedures. Appropriate pre-operative images, as determined by the person performing the procedure, are available for the case. Good quality image Available prior to induction of anesthesia Immediate available for viewing throughout the case If in the clinical judgement of the surgeon there are abnormalities of questions about the films, surgeons are encouraged to conduct a review of preoperative images with an attending radiologist Site marking is completed using appropriate source documents Marking indicates: Anterior or posterior approach General level, i.e. cervical, lumbar, thoracic Laterally, if applicable There are two options as the next step in the process Option One Real time intra- operative imaging, such as fluoroscopy or stereotactic navigation, is used to verify proper placement of instruments. A pause is conducted before executing the procedure. At a minimum, the person performing the procedure must verbalize the level and the procedure team confirms against source documents. Option Two: If real-time intra-operative imaging is not used, the spine level if localized by following the process below: Following incision and exposure of the vertebrae, a fixed anatomic structure is marked with a radiopaque instrument/marker by the surgeon and correct placement confirmed by intraoperative imaging (unless pre-existing landmarks are obvious and sufficient): Radiopaque instrument/marker should remain visible to surgeon throughout the case (when applicable, e.g., cases in which pre-existing landmarks are not obvious and sufficient) or, If removable radiopaque instrument is used during imaging, a durable mark or marker should be paced at the precise location as the instrument and should be placed at the same time the radiopaque instrument is placed. Instrument/marker should be placed on a stable anatomic structure. After marker is placed and imaging available, the individual ultimately responsible for the procedure performs the count of the vertebrae to verify correct level. Any discrepancies between the count, images, and marker are resolved prior to continuing the procedure. A pause is conducted before executing the procedure. At a minimum, the person performing the procedure must identify the marked level on the image, verbalize the level and the OR team confirm against source documents. Wed, 16 Mar 2011 17:48:00 GMT f1397696-738c-4295-afcd-943feb885714:2168 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2161/minnesota-patient-safety-alert-accountability-for-safe-site-key-principles--senior-leadership-action-needed#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2161 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2161&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Accountability for Safe Site Key Principles - Senior Leadership Action Needed https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2161/minnesota-patient-safety-alert-accountability-for-safe-site-key-principles--senior-leadership-action-needed Background Although Minnesota hospitals have been working diligently to eliminate wrong patient, wrong site and wrong procedure adverse events and have experienced success in specific areas, we are on target to experience higher numbers of wrong site procedures than ever before. Examples of wrong site events:  a)  Provider continues to have patients mark their own procedure site; wrong site surgery occurs.  b)  Team does not see the mark, assumes site mark has been removed with surgical prep, does not stop the procedure to verify.  c)  The patient is asked to confirm the operative leg; correct site is not verified with schedule or consent.  d)  A time-out is not conducted for an interventional radiology procedure; procedure is performed on the wrong site. Key issues:    1)  The procedure site mark is not consistently being visualized immediately prior to the procedure start resulting in the procedure being conducted in the wrong location.  In 38% of wrong site cases this year, the procedure site was correctly marked but no one on the team looked for the mark before the start of the procedure.   2)  The anesthesia procedure, such as a block, being conducted prior to a surgical procedure is not consistently being treated as a separate invasive procedure with separate site marking and a time-out conducted, resulting in the anesthesia procedure being administered at the incorrect site.  In 30% of reported cases so far this year, an anesthesia procedure, e.g. block administered prior to a surgical procedure, was completed on the incorrect side/site.    3)  Site marking is not being consistently completed for interventional radiology procedures (interventional radiology procedures in which the procedure site is predetermined need to be site marked) resulting in procedures being performed at the incorrect site.  20% of wrong site procedures last year occurred in interventional radiology.    4)  There are not clear expectations communicated that all surgeons and other providers performing procedures follow the Minnesota site marking and time-out recommendations. 78% of wrong site events this current year had one or more of the key site marking or time-out best practices not completed. Call-to-Action for Senior Leadership Key Best Practices - Visualizing Site Mark During Time-out This is a step in the time-out process that should be clearly assigned (recommend scrub staff for OR). If this step is not completed, providers and staff should know that it is an expectation that they speak up to “stop the line” until the mark has been visualized and communicated to the team. Executive Leadership Actions: Partnership with the Safe Site Surgeon and Operational Champion in your facility to: Meet with the OR and procedure teams to discuss barriers and solutions. Ask OR and procedure staff in areas such as interventional radiology and anesthesia to share observational audit data with you, which includes the percent to time that the site mark was visualized prior to procedure start. Observe site marking and time-outs in action. Key Best Practices - Anesthesia Procedures Preceding Surgical Procedure Anesthesia procedures, such as blocks and injections, should be treated as separate invasive procedures. Site marking by the person performing the procedure, and a time-out by the procedure team, need to be completed for the anesthesia procedure. A second, separate site mark and time- out need to be conducted for the surgical procedure. Executive Leadership Actions: Meet with anesthesia team to discuss barriers and solutions. Ask anesthesia staff to share observational audit data with you which includes the percent of time the anesthesia procedure site was marked and a time‐out conducted.     Observe anesthesia procedure site marking and time‐outs in action. Key Best Practices - Interventional Radiology  All interventional radiology procedures in which the procedure site is pre-determined need to be site marked. Reports from radiologists estimate that approximately 95% of interventional radiology procedures are pre-determined (i.e., the procedure and laterality/location of the procedure to be performed are known). A time-out needs to be conducted by the IR team prior to interventional radiology procedures regardless of whether or not site marking is needed. Executive Leadership Actions: Meet with interventional radiology teams to discuss barriers and solutions. Ask interventional radiology staff to share observational audit data with you which includes the percent of time the procedure site was marked, when the site was pre‐determined, and a time‐out conducted. Ask interventional radiology staff to demonstrate their site marking and time‐out process to you. Observe interventional radiology site marking and time‐outs in action. Key Best Practices - Following Minnesota Time-out and Site Marking Recommendations The procedure site is marked by the practitioner who is ultimately accountable for the procedure; patients should not sign the site.    All key steps of the time-out are completed by the procedure team for any invasive procedure. Executive Leadership Actions: Establish a formal, written “Hard Stop” (nothing moves forward) policy outlining:  If these Safe Site actions are not followed, in any area of the hospital (e.g. OR, anesthesia, interventional radiology) staff and physicians should: Be expected to call a “Hard Stop” (nothing moves forward) until these practices are completed;  Know that they will be supported in stopping the line; Have a clear channel of communication to follow if they are not supported in their immediate environment in calling for the “Hard Stop”;  Know the organization’s expectations and consequences for not practicing these key Safe Site actions. Share the Safe Site actions with your board, along with your hospital’s audit data related to site marking and the time‐out process in the operating room and areas outside the operating room. Tue, 22 Jun 2010 17:19:00 GMT f1397696-738c-4295-afcd-943feb885714:2161 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2165/minnesota-patient-safety-alert-site-marking-not-located-prior-to-procedure-start#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2165 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2165&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Site marking not located prior to procedure start https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2165/minnesota-patient-safety-alert-site-marking-not-located-prior-to-procedure-start Background The Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) have reviewed data from the adverse health event reporting system and have noted that in 38 percent of wrong site procedures reported since October 2009, the correct site was marked by the person performing the procedure, however, the site mark was not located, and its location shared with the procedure team, as part of the time-out process. Root cause analyses reviewed indicate that in most cases the site mark was not visible after prepping and draping and the team proceeded with the procedure without looking for and locating the site mark. Recommendation Marking the site of a surgical or invasive procedure prior to initiation of the procedure is a crucial step in the verification process. However, if that site mark is not visualized during the time-out process, the value of this step is undermined and the final opportunity to prevent a wrong-site or wrong procedure incident may be missed. The community standard for time-out in Minnesota includes visualization and verbal confirmation of the site mark by a member of the operative team as part of a robust, active time- out process.  MHA and MDH recommend that facilities revisit their surgical and other invasive procedure policies and processes to clarify responsibilities for locating the site marking prior to procedure start as part of the time-out process.  It is also recommended that observational audits be performed to observe whether or not this step of the process is being completed on a consistent basis. The Minnesota time-out recommendations include the following steps: Surgeon: Initiates the time-out 4   Circulator: Reads aloud the patient’s name, 2nd identifier, procedure and procedure site from the informed consent document that has been previously verified during pre-op and asks the team to verify. Anesthesia Care Provider: States patient’s name, 2nd patient identifier and procedure (can be short-hand version of the procedure) with laterality if appropriate. Scrub Person: 1st – Verifies which procedure they have prepped — can be a shorthand version of the procedure; 2nd – Visualizes the mark, verbally indicating that he/she sees the mark and where it is located. Surgeon: States full procedure; asks scrub person to remove the time-out towel to begin the procedure. Thu, 22 Apr 2010 18:45:00 GMT f1397696-738c-4295-afcd-943feb885714:2165 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2157/minnesota-patient-safety-alert-accounting-for-removal-of-packing-materials-used-during-surgical-procedures#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2157 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2157&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Accounting for removal of "packing" materials used during surgical procedures https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2157/minnesota-patient-safety-alert-accounting-for-removal-of-packing-materials-used-during-surgical-procedures Background The Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) have reviewed data from the adverse health event reporting system and have noted a cluster of retained foreign objects involving materials used for packing that are intended to be removed following the procedure but are not removed as intended. Root cause analyses reviewed indicate that in most cases the placement of the packing is not clearly communicated and documented, a process for ensuring removal is not well defined and accountability for removal of the item is not clearly assigned. A high percentage of reported cases involve retained vaginal packs following procedures such as suburetheral sling or cystocele repair. Recommendation MHA and MDH recommend that facilities revisit their surgical policies and processes to address the issue of ensuring items that are used for packing are removed as intended. The following suggestions should be considered in developing processes within your organization: Packed items are communicated to the team; The item placed, and its location, is documented in a manner that it can be accounted for at the end of the case; There is a clear process for accounting for packed items at the end of the case; An order is written by the physician for packing removal indicating when the packing should be removed; The presence of packed materials is communicated during hand-off to post-procedure staff; A standardized process and clear accountability is in place for removal of the item post- procedure. For example: A flag is placed in the medical record, visible across departments, that is present until the packing is removed. Tue, 18 Aug 2009 20:05:00 GMT f1397696-738c-4295-afcd-943feb885714:2157 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2164/minnesota-patient-safety-alert-ensuring-objects-used-during-invasive-procedures-are-intact#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2164 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2164&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Ensuring objects used during invasive procedures are intact https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2164/minnesota-patient-safety-alert-ensuring-objects-used-during-invasive-procedures-are-intact Background The Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) have reviewed data from the adverse health event reporting system and have noted a cluster of retained foreign objects involving devices or instruments in which a component of the object (e.g., an insertion tip or sleeve) is retained or a piece of an object breaks and is retained (e.g., a guide wire used during a biopsy, a catheter tip breaking upon removal or a piece of a drill bit used during an orthopedic procedure). The root cause analyses reviewed for these events indicate that there may not be clear policies in place to assign responsibility for visual inspection of devices and instruments pre- or post-procedure to check for broken or missing components. In some cases, surgical teams may not be aware that a particular device has multiple components that can break or separate, or are not aware that certain components need to be removed when a device is implanted, indicating training and communication as additional contributing factors. Recommendations MHA and MDH recommend that facilities revisit their surgical and other invasive procedure policies and processes to address the issue of ensuring objects used in procedures are intact. The following suggestions should be considered in developing processes within your organization: Responsibility is assigned to a specific team role for visualization of equipment/devices that will be used during the procedure to ensure the device and all of its components are intact prior to the procedure and that the device is intact and all components are accounted for following the procedure. Before deployment of a new device or equipment, staff should be educated on all component parts of the object that could potentially be retained or may be at higher risk for breakage.    Any breakage or separation of device components during a procedure, even if the object is not retained, should be tracked to identify potentially higher-risk devices or instruments for breakage. Additional Actions Implemented by Hospitals Reporting Broken Retained Objects Verification of wire barb removal will take place prior to skin closure through either mammogram or pathology examination of specimen. When possible, device or equipment with removable parts will be replaced with equally effective devices or equipment without removable parts. Work with vendor to modify devices or equipment at higher-risk for breakage or separation. For more information on this alert, contact Julie Apold, MHA director of patient safety, at japold@mnhospitals.org or (651) 641-1121 or toll-free at (800) 462-5393 or Diane Rydrych, Assistant Director, Division of Health Policy, MN Department of Health, 651-201-3564 Thu, 30 Apr 2009 19:40:00 GMT f1397696-738c-4295-afcd-943feb885714:2164 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2170/minnesota-patient-safety-alert-bassinet-fire-investigation-complete#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2170 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2170&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Bassinet Fire Investigation Complete https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2170/minnesota-patient-safety-alert-bassinet-fire-investigation-complete Root cause identified in infant warmer fire A team of nationally-recognized experts has concluded that the fire that occurred in an infant bassinet at Mercy Hospital on Jan. 22, 2008 was most likely caused by a hot particle falling from the bassinet’s warmer assembly into the oxygen-enriched environment near the infant’s head. Microscopic investigation revealed several sites of overheating and thermal damage in the warmer head area that was the likely source of the particle that fell into the bassinet and caused the fire. The warmer’s design and construction did not adequately safeguard the bassinet from exposure to a hot particle potentially generated and dropped during normal operation.  The actual defects in the heater were not visible to the naked eye and could not be detected by the maintenance, repair, calibration and routine inspection performed by clinical engineering staff. The warmer involved in the incident was a Hill-Rom 1250. The investigators recommend that Allina no longer use this warmer for any purpose. In addition, they also recommend taking the following similar warmers out of service at Allina: Borning models 200 and 300, and Hill-Rom models 1500, 2000/3000, 2000, 2200/3200, 3000 and 3200. These Hill- Rom model numbers may be followed by the letters A, B or C. ECRI Institute will soon release a set of recommendations for other health care facilities that use these warmers. For more information on the Patient Safety Registry, adverse health event reporting or this alert, contact Julie Apold, MHA director of patient safety, at japold@mnhospitals.org or (651) 641-1121 or toll-free at (800) 462-5393. Thu, 15 Jan 2009 18:31:00 GMT f1397696-738c-4295-afcd-943feb885714:2170 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2167/minnesota-patient-safety-alert-incorrect-information-in-source-document-used-to-verify-procedures#Comments 1 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2167 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2167&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Incorrect Information in Source Document Used to Verify Procedures https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2167/minnesota-patient-safety-alert-incorrect-information-in-source-document-used-to-verify-procedures Background Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) have reviewed data from the adverse health event reporting system and have noted a cluster of wrong invasive procedures that have resulted from failure to identify incorrect information in source documents used in pre-operative verification. Recommendation MHA and MDH recommend that facilities revisit the source documents and verification procedures that are used to schedule procedures, complete informed consent documents, and perform pre-operative verification. While research is inconclusive regarding best practices for use of source documents and verification, the following suggestions should be considered in developing processes within your organization: Discussions with local and national experts have suggested facilities consider “5 Rights of Verification” — the procedure to be performed is verified against:    Provider’s surgical/procedure order;  Radiology and pathology reports — if relevant to procedure;  Informed consent documentation; o Patient’s understanding of the procedure to be performed;    Diagnostic imaging (properly labeled, displayed and viewed along with the radiologist’s report). There are other documents that could be included in this list of source documents such as the provider’s pre-procedure note. If there is a discrepancy in any of the source documents, the history and physical diagnosis and plan can be utilized to help in the reconciliation process. While efforts should be made to improve the accuracy of the operating room/procedure room schedule, the schedule should not be used as a source for verification of patient or procedure. Analysis performed by David Marx, Outcome Engineering LLC, estimates that assigning one person to perform verification using a single source document, e.g. the informed consent document, results in a failure rate of 1 in 1,000 procedures. Adding a second person to perform an independent verification using two source documents, e.g. surgical order and history and physical, decreases the failure rate to 1 in 100,000 procedures. A third independent verification using three source documents decreases the failure rate to 1 in 1 million. Independent documents should be used wherever possible rather than using one source document that is also the basis for subsequent documents. Relying on dependent sources of information could allow for an error to be carried through the process. A pre-procedure checklist detailing the verification of multiple source documents by independent reviewers should be completed prior to any invasive procedure. The procedure should not proceed until the checklist is complete and reconciled. The organization’s policy and checklists related to pre-procedure verification should include a clear description of who is responsible for verifying the procedure against each of the sources of information, along with a clear process and assignment of responsibility for reconciling discrepancies among any of the information sources prior to the procedure. The policy should require not only that relevant imaging be available prior to the procedure, but also that it be viewed, along with the radiologist’s report, as part of the pre-procedure verification process. For more information on the Patient Safety Registry, adverse health event reporting or this alert, contact Julie Apold, MHA director of patient safety, at japold@mnhospitals.org or (651) 641-1121 or toll-free at (800) 462-5393 Fri, 11 Apr 2008 18:16:00 GMT f1397696-738c-4295-afcd-943feb885714:2167 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2163/minnesota-patient-safety-alert-potential-for-retained-laparoscopic-argon-beam-coagulator-tip#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2163 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2163&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Potential for Retained Laparoscopic Argon Beam Coagulator Tip https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2163/minnesota-patient-safety-alert-potential-for-retained-laparoscopic-argon-beam-coagulator-tip A report submitted to the Patient Safety Registry highlighted a potential issue with a change in the protector of a laparoscopic argon beam coagulator manufactured by CONMED. Previously the protector for this device was bright yellow. Recently a change was made to the instrument — the current models have a smaller black protector, which is the same color as the shaft of the instrument. The packaging of the new instrument contains a warning to “remove the yellow protector before use” and has not been updated to correspond with the change to the black protector. These factors may increase the chances of the protector not being removed thus potentially resulting in a retained foreign object. The manufacturer has been notified of these concerns. MHA and MDH would appreciate your help in notifying the appropriate staff within your facilities of this potential patient safety issue. Wed, 02 May 2007 16:00:00 GMT f1397696-738c-4295-afcd-943feb885714:2163 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2171/minnesota-patient-safety-alert-wrong-sidewrong-lens-eye-procedures#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2171 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2171&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Wrong side/wrong lens eye procedures https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2171/minnesota-patient-safety-alert-wrong-sidewrong-lens-eye-procedures Background MHA and MDH have reviewed data from the adverse health event reporting system and have noted a cluster of invasive eye procedures that have resulted in either the procedure being performed on the wrong eye or the wrong lens being inserted into the eye. Facilities have found that these events have occurred primarily due to inconsistent or ineffective processes for marking the correct eye and/or non-existent or ineffective verification/ “time-out” processes being followed prior to the regional block or procedure. Recommendation MHA and MDH recommend that facilities implement the Safest in America/Institute for Clinical Systems Improvement Safe Site Protocol for Invasive and Surgical Procedures that was updated in January, 2006 (see PDF) for invasive eye procedures. A Joint Statement of the American Academy of Ophthalmology (AAO), the American Society of Ophthalmic Registered Nurses (ASORN) and the American Association of Eye and Ear Hospitals (AAEEH) provides additional specific suggestions for verifying the operative eye and minimizing wrong incorrect intraocular lens (IOL) placement. Suggestions for a Checklist to Verify the Operative Eye *Developed by the AAO Quality of Care Secretariat in collaboration with ASORN and AAEEH, March 2001 The patient’s informed consent form describes the operative eye (e.g., right eye, left eye, abbreviations are not acceptable), and the patient understands which eye is being operated on and which procedure is being performed. The ophthalmic history and exam are available in the operating room. Prior to administration of eye drops or medication, the nurse asks the patient which eye is being operated on.  The patient’s response, the informed consent, the doctor’s orders for medication or dilation of the operative eye, and the ophthalmic history and exam all match for operative eye. The surgeon/assistant surgeon marks the skin next to the operative eye with his/her initials.  Prior to administration of anesthetic injection or sedation, the anesthesia staff /surgeon verify the operative eye with the patient, informed consent and/or the ophthalmic history and exam, and they all match. Immediately prior to incision, the surgeon verifies the operative eye with the ophthalmic history and exam. If there is any discrepancy among the patient’s response, the informed consent, the doctor’s orders, ophthalmic history and exam, the surgeon makes the final determination and the discrepancy is corrected before proceeding with the procedure. Suggested Multiple IOL Verification Procedure in the Operating Room for Minimizing Wrong IOL Placement **Developed by the AAO Quality of Care Secretariat in collaboration with ASORN and AAEEH, March 2001. The ophthalmic history and exam and form that contains keratometry and axial length, primary and alternate lens/es for each patient are available in the operating room. •      If at all possible, there should only be one IOL measurement per eye on the form. If your computerized IOL measurement program allows, refrain from printing measurements for the left and right eyes on one form. The surgeon/ assistant surgeon selects the primary and alternate IOL/s before the start of the case. The surgeon verifies the IOL number, diopter, optic, A constant, and length against the IOL Calculation Report form or documentation and/or patient medical record. Before incision or when the surgeon requests the IOL, the circulating nurse shows the IOL box to the surgeon. The surgeon and circulating R.N. verify the IOL model, power and other calculation information, patient identification, and operative eye against the IOL Calculation Report. The circulating nurse then repeats this procedure with the scrub nurse/technician (i.e. shows the IOL box and verbally states the model number and lens power). •      The scrub nurse/technician verbally states the model number and lens power as he/she passes the lens to the surgeon for implantation. The surgeon may elect to perform visual inspection of the IOL under the microscope for appropriateness and any lens defect or deposit. If there is a discrepancy, the surgeon reviews the IOL Calculation Report or ophthalmic history and exam and /or designated institute form. The circulating nurse puts the IOL labels on the IOL card, operative record/patient chart right after the surgeon implants the IOL. He/she documents the IOL verification procedure in the patient record. For more information on the Patient Safety Registry, adverse health event reporting or this alert, contact Julie Apold, MHA patient safety registry manager, at japold@mnhospitals.org or (651) 641-1121 or toll-free at (800) 462-5393. *AAO DISCLAIMER:  These are suggested ideas for a checklist; however, they may not be appropriate, feasible or desirable in all settings and for all patients. This checklist should not be deemed inclusive of all proper methods to verify the operative eye, or exclusive of other protocols that are reasonable at obtaining the same results. The ultimate judgment regarding the utility and application of suggestions listed herein must be made by the operating surgeon (in collaboration with nursing and anesthesia staff) in light of all the circumstances presented by the patient, setting of care, and other factors. **AAO DISCLAIMER: These are suggested ideas for verification procedure. However, they may not be appropriate, feasible or desirable in all settings and for all patients. This verification procedure should not be deemed inclusive of all proper methods to verify the appropriate IOL, or exclusive of other protocols that are reasonable at obtaining the same results. The ultimate judgment regarding the utility and application of suggestions listed herein must be made by the operating surgeon (in collaboration with nursing staff) in light of all the circumstances presented by the patient, setting of care, and other factors. Tue, 09 Jan 2007 18:16:00 GMT f1397696-738c-4295-afcd-943feb885714:2171 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2158/minnesota-adverse-health-event-alert-conducting-a-pre-operative-checklisteffective-time-out#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2158 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2158&PortalID=0&TabID=578 Minnesota Adverse Health Event Alert: Conducting a Pre-Operative Checklist/Effective "Time-Out" https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2158/minnesota-adverse-health-event-alert-conducting-a-pre-operative-checklisteffective-time-out Background Minnesota Hospital Association (MHA) has reviewed data from hospitals that have agreed to share adverse health reporting information and has noted commonalities in submitted root causes for wrong body part surgical events. The majority of root cause analyses indicate that a “Time-Out/Pause for the Cause” prior to the invasive procedure, regional block, or surgery was either not conducted or was not effectively conducted. Recommendation MHA recommends that all hospitals implement the Safest in America/Institute for Clinical Systems Improvement Safe Site Protocol for Invasive and Surgical Procedures that was updated in January 2006: [see PDF]. The protocol is consistent with the JCAHO Universal Protocol and provides additional specifications, special considerations and a Surgical Procedure Checklist [see Word DOC] and a Non-OR Invasive Procedure Checklist that can be incorporated into pre-procedure processes: [see Word DOC]. Hospitals have found increased success with completion of the protocol steps by automatically printing out these pre-procedure checklists along with their informed consent documents to help ensure that the checklist is completed for each surgical and invasive procedure. Hospitals have shared additional learnings to help ensure that the “Time-Out” or “Pause for the Cause” component of the checklist is successfully completed. The “Time-Out” should: be completed just prior to the procedure; be conducted in a quiet environment — no talking, music, etc; include active participation by the full team — all members of the team should know that they can safely speak up if they suspect a problem; and include one individual who is responsible for ensuring that the pause is conducted. Based on information reported into the Patient Safety Registry, the Minnesota Hospital Association has worked with the members of MHA’s Patient Safety & Registry Advisory Council to prepare this alert.    For more information on the Patient Safety Registry, adverse health event reporting or this alert, contact Julie Apold, MHA patient safety registry manager, at japold@mnhospitals.org or (651) 641-1121 or toll-free at (800) 462-5393. Mon, 31 Jul 2006 19:58:00 GMT f1397696-738c-4295-afcd-943feb885714:2158 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2166/minnesota-adverse-health-event-alert-healthcare-industry-representatives#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2166 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2166&PortalID=0&TabID=578 Minnesota Adverse Health Event Alert: Healthcare Industry Representatives https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2166/minnesota-adverse-health-event-alert-healthcare-industry-representatives Background A report submitted to the patient safety registry describes a case in which a manufacturer’s sales representative who was present in an operating room provided the wrong product to the operating room staff. This product was then used in the procedure, resulting in an adverse outcome to the patient. This event, and a recent article by the Patient Safety Authority in Pennsylvania entitled, “Healthcare Industry Representatives: Maximizing Benefits and Reducing Risks,” highlights the need to reduce risk associated with the presence of manufacturer’s representatives during surgical procedures. MHA and MDH recommend that all hospitals and ambulatory surgical centers review their practices and policies to ensure that clear requirements and procedures are in place governing the presence of manufacturer’s representatives in the operating room and their interaction with operating room staff. The Pennsylvania article mentioned above offers additional information and resources. This issue is also addressed in the 2005 position statements of the American College of Surgeons and The Association of Perioperative Registered Nurses. Fri, 21 Apr 2006 18:34:00 GMT f1397696-738c-4295-afcd-943feb885714:2166 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2169/minnesota-patient-safety-alert-patient-protection-suicide-by-hanging#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2169 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2169&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Patient Protection- Suicide by hanging https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2169/minnesota-patient-safety-alert-patient-protection-suicide-by-hanging MDH has reviewed data from the patient safety registry and has noted suicide by hanging via door hardware. A review of these events shows two common root causes: 1. environment and equipment; 2. staff training and education of suicide assessments and precautions. Background  Nationally, inpatient suicide by hanging mostly occur in bathrooms, bedrooms, or closets and have occurred in psychiatric facilities, acute care hospitals, residential care facilities, and in emergency rooms.  A large percentage of all hanging suicides are not fully suspended, meaning the ligature points (beams, hooks, banisters) are below head level. Staff training and education of suicide assessments and precautions The Joint Commission International Center for Patient Safety lists strategies for improving patient suicide risk assessments and staff education, and are highlighted below: Use a standardized suicide risk assessment/reassessment procedure Implement education for family/ friends regarding suicide risk factors    Enhance staff orientation/education regarding suicide risk factors MDH recommends that all facilities, especially those with behavioral health units, review their environmental and patient safety policies regarding patient suicide prevention, assess the knowledge of relevant staff of suicide risk factors, and review suicide risk assessment /reassessment procedures. Suggested resources: The epidemiology and prevention of suicide by hanging: a systematic review. (abstract) http://ije.oxfordjournals.org/cgi/content/abstract/34/2/433 Mon, 27 Feb 2006 18:37:00 GMT f1397696-738c-4295-afcd-943feb885714:2169 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2156/minnesota-patient-safety-alert-procedures-performed-outside-of-the-operating-room#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2156 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2156&PortalID=0&TabID=578 Minnesota Patient Safety Alert: Procedures performed outside of the operating room https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2156/minnesota-patient-safety-alert-procedures-performed-outside-of-the-operating-room Background MHA has reviewed data from hospitals that have agreed to share adverse health event reporting information and has noted a cluster of wrong body part events related to chest procedures.  Review of these events shows that these invasive procedures were performed outside the operating room (e.g. patient’s room, radiology department) and a “Time Out/Pause for the Cause” (pause and verification just prior to the incision or injection) was not conducted.   The Safest in America “Safe Site Protocol for Invasive and Surgical Procedures” (available at http://www.mnhospitals.org/inc/data/pdfs/SIA_ISCI_protocol.pdf) recommends pause and verification for all invasive procedures which should take place in the location where the procedure will be done.  This protocol is not limited to the operating room. Recommendation MHA recommends that all hospitals review their policies for invasive procedures performed outside of the operating room.  It is also recommended that hospitals have a system in place to check if pause and verification is taking place in these settings (in some instances it was thought that the process was taking place but there was confusion as to which settings the pause and verification process applied). Some Minnesota hospitals are developing a process in which a pause and verification checklist is automatically printed with each informed consent document and are standardizing their protocols and forms across their organizations. Mon, 03 Oct 2005 20:10:00 GMT f1397696-738c-4295-afcd-943feb885714:2156 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2160/minnesota-patient-safety-alert#Comments 3 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2160 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2160&PortalID=0&TabID=578 Minnesota Patient Safety Alert https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2160/minnesota-patient-safety-alert A Minnesota hospital recently had an incident occur in which a Datascope MR Monitor was brought into the MRI room in preparation for conscious sedation. The monitor was pulled into the magnetic field and forcibly attached to the MRI bore. Thankfully there were no injuries.    MHA recommends that all hospitals check any similar equipment for MRI compatibility.          The Minnesota Hospital Association has worked with the members of MHA’s Patient Safety & Registry Advisory Council to prepare this alert.    For more information on this alert, contact Julie Apold, MHA patient safety registry manager, at japold@mnhospitals.org or (651) 641-1121 or toll free at (800) 462-5393. Thu, 21 Jul 2005 19:34:00 GMT f1397696-738c-4295-afcd-943feb885714:2160 https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2172/minnesota-adverse-health-event-alert#Comments 0 https://www.mnhospitals.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=578&ModuleID=2159&ArticleID=2172 https://www.mnhospitals.org:443/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2172&PortalID=0&TabID=578 Minnesota Adverse Health Event Alert https://www.mnhospitals.org/quality-patient-safety/adverse-health-events/safety-alerts/id/2172/minnesota-adverse-health-event-alert A telemetry device manufacturer had programmed a monitoring alarm function so it was in the “off” position and had not made this known to the hospital at the time of purchase. This “off” position prevents the alarm from signaling in the event of a low or failed battery or when the device’s leads become disconnected from the patient. An adverse patient outcome occurred when the unit’s alarm did not signal a problem and there was delay in treating a patient. MHA recommends that all hospitals work closely with their clinical and biomedical staff and manufacturers of monitoring equipment to put systems in place to ensure that all alarm functions are appropriately programmed and used in the “on” position and are tested frequently to verify they are in the “on” position. Based on information reported into the Patient Safety Registry, the Minnesota Hospital Association has worked with the members of MHA’s Patient Safety & Registry Advisory Council to prepare this alert.  For more information on the Patient Safety Registry, adverse health event reporting or this alert, contact Julie Apold, MHA patient safety registry manager, at japold@mnhospitals.org or (651) 641-1121 or toll free at (800) 462-5393. Fri, 01 Apr 2005 18:12:00 GMT f1397696-738c-4295-afcd-943feb885714:2172