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 www.patientsafetyauthority.org.

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 www.patientsafetyauthority.org.

SOURCE Pennsylvania Patient Safety Authority

Laurene M. Baker of Pennsylvania Patient Safety Authority, +1-717-346-1092