hit related question 2015 pennsylvania patient safety authority annual report

How common is hit as a factor in Pennsylvania medication errors?

A total of 889 medication-error reports listed HIT as a factor contributing to the event submitted to the Pennsylvania Patient Safety Authority between January 1and June 30, 2016. The three most commonly reported event types were dose omission (n = 123), wrong dose/overdosage (n = 97), and extra dose (n = 95).

How does hit affect patient safety?

Although the application of HIT can help improve safety and quality, if not implemented well it can have devastating consequences on patient safety. A total of 889 medication-error reports listed HIT as a factor contributing to the event submitted to the Pennsylvania Patient Safety Authority between January 1and June 30, 2016.

Can I reprint or distribute the Pennsylvania Patient Safety Advisory?

The Pennsylvania Patient Safety Advisory may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration, provided the source is clearly attributed.

What are the most common hit systems implicated in drug abuse?

The most common HIT systems implicated in the events were the computerized prescriber order entry system (CPOE; n = 448), the pharmacy system (n = 251), and the electronic medication administration record (eMAR; n = 250).

When did the PA-PSRS guidelines go into effect?

The guidance was devel-oped to help provide consistent standards to acute healthcare facilities in Pennsylvania in determining whether occurrences within facilities meet the stat-utory definitions of serious events, incidents, and in-frastructure failures as defined in section 302 of the

What is an event that could have resulted or did result in harm to a patient?

An event, occurence, or condition that could have resulted or did result in harm to a patient and can be but is not necessarily the result of a defective sys-tem or process design, a system breakdown, equip-ment failure or human error. They can also include adverse events, no-harm events, near misses, and hazardous conditions.

What is the PSA 2020?

Like everyone, much of the PSA’s efforts in 2020 focused on COVID-19. Once news of the pandemic hit , the field staff, led by our team of infection pre-ventionists, began providing virtual consultations for healthcare facilities across Pennsylvania cov-ering everything from cleaning protocols to ob-taining additional personal protective equipment. Sometimes the team just provided emotional sup-port for frontline staff during their darkest hours.

What is the MCARE Act?

The MCARE Act requires each medical facility to des-ignate someone to serve as that facility’s patient safety ocer (PSO). In addition to other duties, the MCARE Act requires the PSO to submit reports to the PSA.

What is a potential adverse event?

“potential adverse event”: An event which either did not reach the patient (“near miss”) or did reach the patient but the level of harm did not require addi-tional healthcare services. The legal definition from the MCARE Act: “an event, occurrence, or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional healthcare services to the patient. The term does not include a serious event.”

What is a PSA analyst?

The analyst is a member of the PSA with education and experience in medicine, nursing, pharmacy, product engineering, statistical analysis, and/or risk management. Analysts review events submit-ted through PA-PSRS and compose the majority of the articles included in the PSA’s quarterly, peer-re-viewed journal, Patient Safety.

How long do you have to report a patient in restraints?

The Centers for Medicare & Medicaid Services (CMS) requires hospitals to report to DOH any death of patients in restraints or in seclusion, or in which restraints or seclusion were used within 24 hours of death (other than soft wrist restraints).

Abstract

Introduction

Methods

• The HIT-related question was introduced into PA-PSRS in April 2015.8 Based on data from the Pennsylvania Patient Safety Authority 2015 Annual Report, a 45% increase occurred in the number of HIT-related medication error reports received between the second (n = 274) and fourth quarters (n = 397) of 2015.8 In light of the changing nature of facility ...

See more on patientsafety.pa.gov

Results

Discussion

Limitations

Strategies

Conclusion

Notes