Studies in Patient Safety
Summer 2008 (Vol. 5 No. 2) Abstracts
Abstract for Article 1:
Care at Discharge—A Critical Juncture for Transition to Posthospital Care
Discharge is a critical juncture for transitioning to posthospital care, and incomplete discharge processes may cause harm to patients.
From June 2004 to December 2007, more than 800 reports were submitted from hospitals through PA-PSRS identifying a variety of problems occurring at discharge. Approximately 30 percent of patients did not receive verbal or written discharge instructions before they left the facility. Lack of medication reconciliation was also evident.
Essential components of the discharge process include educating the patient and his or her family, assessing the patient’s understanding of the plan, scheduling follow-up appointments, organizing postdischarge services, confirming the medication plan, and reviewing with the patient what to do if a problem occurs. Understanding the pertinent requirements of healthcare regulatory agencies is an important part of discharge planning.
Implementation of discharge planning upon patient admission, assignment of discharge coordinators, and use of checklists to facilitate standardization within the facility are risk reduction strategies to consider. (Pa Patient Saf Advis 2008 Jun;5[2]:39-43.)
Abstract for Article 2:
Prevention of Inadvertent Perioperative Hypothermia
Perioperative hypothermia may result in serious cardiac, coagulation, and wound-healing complications, especially among vulnerable pediatric and elderly patients. More than 50 reports have been submitted through PA-PSRS about patients experiencing perioperative hypothermia.
Many reports involved hypothermia that was detected in the postanesthesia care unit. Only a few reports indicated that measures were in place to prevent hypothermia.
Risk reduction strategies to prevent perioperative hypothermia include assessing the patient for increased risk of hypothermia, monitoring temperature throughout the perioperative period using optimal temperature monitoring sites, and using active and/or passive warming measures as appropriate. (Pa Patient Saf Advis 2008 Jun;5[2]:44-52.)
Abstract for Article 3:
Sterile Water Should Not be Given "Freely"
Severe hypernatremia can be challenging to treat. There appears to be a failure among healthcare practitioners to recognize the danger of infusing plain sterile water intravenously. Bags of sterile water for injection and inhalation also are being mistaken for intravenous (IV) solutions. Sterile water is hypotonic (0 mOsm/L).
Serious patient harm, including hemolysis, can result when it is administered by direct IV infusion. PA-PSRS and other medication error reporting programs have received reports of IV administration of sterile water to patients, some of which have resulted in patient deaths.
Risk reduction strategies include recognizing the problem, developing protocols to treat hypernatremia, establishing safeguards, assessing for safe storage, and ensuring that sterile water bags cannot be provided without prior pharmacy agreement and supervision. (Pa Patient Saf Advis 2008 Jun;5[2]:53-6.)
Last Updated: 9/12/2008