Newborns Pose Unique Identification Challenge in Pennsylvania
Scabies, Health Literacy, and Innovation also featured in the June 2016 Pennsylvania Patient Safety Advisory
HARRISBURG, Pa., June 16, 2016 /PRNewswire-USNewswire/ -- An average of nearly two newborn misidentification events occur daily in Pennsylvania, according to estimates from the Pennsylvania Patient Safety Authority.
"Unique characteristics of the newborn population pose challenges for accurate and consistent patient identification," said, Ellen S. Deutsch, MD, MS, FACS, FAAP, medical director for the Authority. "Hospitalized newborns often share similar birth dates and medical record numbers and, with multiple births, even share surnames."
Authority analysts noted limited literature available specific to identification errors in newborns at a population level; however, analysts found 1,234 newborn identification events reported to the Authority (occurring from January 2014 through December 2015).
The majority of reported events involved procedure errors (e.g., mislabeled specimens), followed by general misidentification errors (e.g., missing or mismatched identification bands), medication events, and breast milk administration mishaps. Most events were reported as Incidents or "near misses" (events that do not harm the patient). Five events were reported as Serious Events (events that harm the patient), including events in which the wrong breast milk was given to the patient and a circumcision was performed without consent.
Analysts extrapolated contributing factors from the event reports. The resulting article provides risk reduction strategies, learning objectives, and self-assessment questions for hospital and birthing center professionals. "The information can be a start to ongoing discussions that purposefully address newborn identification errors in healthcare facilities," said Deutsch. "Safety huddling, distinct naming systems, clinician awareness, and technology such as bar coding may help to decrease newborn identification errors in the future."
Additional articles in this issue of the Pennsylvania Patient Safety Advisory offer in-depth data analysis, education, resources, guidance, and strategies about the following:
Scabies in Pennsylvania Healthcare Facilities: Key elements include the management and control of outbreaks in nursing homes and acute care facilities, particularly among the more vulnerable populations of older adults and those who are immunocompromised.
Click here for more information and educational tools on the control and management of scabies
Health Literacy: The discussion highlights strategies for providers to help patients maintain better engagement in their medical care.
Click here for more information and the Authority's interactive tool to promote health literacy
Medication Errors Associated with Incorrect Patient Weights: This update offers strategies that include obtaining a current, accurate weight and documenting and communicating patient weights in metric units to avoid dangerously incorrect medication dosages.
C-Diff: This data snapshot illustrates the incidence of Clostridium Difficile infections in long-term care facilities.
Wrong-Site Surgery: An update on utilizing patient engagement to increase the effectiveness of the universal protocol to help prevent wrong-site surgery; which includes two patient identifiers, open communication with patients and caregivers, and patient inclusion in site marking.
Click here to download the patient-centered poster emphasizing universal protocol
Click here for more information and educational tools for the prevention of wrong-site surgery
As the Authority continues to provide quality analysis and education to healthcare professionals and empower patients and families through its Consumer Tips Guide for Patients and Their Families its new Executive Director, Regina Hoffman, plans to lead that charge through innovation. "We will use innovation to enhance our existing projects and services while pushing boundaries to help facilities develop unique insights into patient safety and discover untapped opportunities," said Hoffman. From the timely and progressive patient safety information highlighted in this Pennsylvania Patient Safety Advisory, to the agency's focus on healthcare facilities as essential partners in collaborative improvement, the Authority is determined to move the patient safety bar to the next tier across Pennsylvania.
Download the complete issue of the June 2016 Patient Safety Advisory here.
About the Pennsylvania Patient Safety Authority: The Authority was established under Act 13 of 2002, the Medical Care Availability and Reduction of Error ("Mcare") Act, as an independent state agency. The Authority is charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. For more information about the Authority, please visit our website at www.patientsafetyauthority.org or call 717-346-0469.
Like the Authority on Facebook
Follow the Authority on Twitter
Photo - http://photos.prnewswire.com/prnh/20160616/380327
SOURCE Pennsylvania Patient Safety Authority
Share this article