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I AM Patient Safety Nomination Period Process breakdowns that increase the risk of PATIENT respiratory infection An in-depth look at SAFETY nonsuicidal self-injury September 2020 | Vol. 2, No.3 Fall prevention: Think you’ve already tried everything? Think again. National Action Plan: Yes, every healthcare system is unique. But we have more in common than you think. Patient Safety I September 2020 I 1 LETTER From the Editor Today, September 17, we celebrate tive pieces related to the current World Patient Safety Day with all pandemic, one from a patient who patients, healthcare workers, and discusses his illness and recovery, healthcare organizations. This is- and one from a social worker who sue features an interview with Dr. brings attention to another dan- Tejal Gandhi and Dr. Jeff Brady, ger during periods of isolation— who discuss the recently released intimate partner violence. Other National Action Plan for Patient highlights from this issue include Safety in the United States and an original article that explores share their personal views on its nonsuicidal self-injury among background and importance. I children and adolescents, and an had the honor and privilege of be- inspiring piece that introduces us ing part of the team that developed to a high schooler who has her eye this guiding document, and while on the prize of making the world a I am proud of the work, it under- safer place! scores the challenging road that lies ahead and the need to work in If you have research, improvement alliance with each other. Together initiatives, or perspectives that we can make a difference, and we contribute to our collective knowl- need to start right now. From cul- edge, please consider submitting ture and leadership to learning or- your next manuscript to Patient ganizations and workforce safety, Safety at patientsafetyj.com. Regina Hoffman, this plan encompasses real actions Stay safe and be well! Editor-in-Chief that healthcare facilities can take Patient Safety today to reduce harm to patients. In further support of global pa- can’t believe it’s been a year tient safety, you will find an old since we launched the inaugu- topic in this issue with a fresh ral issue of Patient Safety. Over twist: authors Caitlyn Allen and the course of the past year Susan Wallace take you on a trip IPatient Safety has reached almost around the world in search of in- 29,000 readers from around the novative solutions to patient falls. world. We’d like to thank all our au- In this issue we also include a very thors, reviewers, readers, and staff timely original article that dis- for contributing to this success. We cusses process breakdowns that continue to focus on publishing can lead to failure to recognize, information that both advises and treat, and prevent the spread of inspires providers and patients to respiratory infections. In the time take action to improve patient safe- of COVID-19 and with flu season ty. We encourage researchers, cli- quickly approaching, the recom- nicians, and patients everywhere mendations in this manuscript to share their successes, their chal- are critical to keeping some of our lenges, and their stories with us so most vulnerable patients safe. You we can share them with you. will also find two unique perspec- 2 I PatientSafetyJ.com I September 2020 +++ ABOUT PATIENT SAFETY Mark Jarrett, MD, MBA, MS, Northwell Health Matthew Keris, Esq., Marshall, Dennehey, Warner, Coleman & Goggin As the journal of the Patient Safety Authority, committed to the vision of Stephen Lawless, MD, Nemours Children’s Health System “safe healthcare for all patients,” Patient Safety (ISSN 2689-0143) is fully Michael Leonard, MD, Safe & Reliable Healthcare, LLC open access and highlights original research, advanced analytics, and hot James McClurken, MD, Doylestown Health, Lewis Katz School of Medicine at topics in healthcare. Temple University The mission of this publication is to inform and advise clinicians, admin- Patrick J. McDonnell, PharmD, Temple University School of Pharmacy istrators, and patients on preventing harm and improving safety, by Dwight McKay, BSL, Lancaster Rehabilitation Hospital providing evidence-based, original research; editorials addressing current Ferdinando L. Mirarchi, DO, UPMC Hamot and sometimes controversial topics; and analyses from one of the world’s Dona Molyneaux, PhD, RN, Frances M. Maquire School of Nursing and Health largest adverse event reporting databases. Professions, Jefferson Health; Gwynedd Mercy University Gina H. Moore, BSN, RN, Christiana Care Health Services We invite you to submit manuscripts that align with our mission. We’re Rustin B. Morse, MD, Nationwide Children’s Hospital particularly looking for well-written original research articles, reviews, Adam Novak, MA, Michigan Health & Hospital Association commentaries, case studies, data analyses, quality improvement studies, Barbara Pelletreau, MPH, RN, Dignity Health or other manuscripts that will advance patient safety. Julia C. Prentice, MSPH, PhD, Betsy Lehman Center for Patient Safety All articles are published under the Creative Commons Attribution – Mitesh Rao, MD, MHS, Stanford School of Medicine Noncommercial license, unless otherwise noted. The current issue is Cheryl Richardson, MPH, RN, Penn State Milton S. Hershey Med. Center available at patientsafetyj.com. Lisa Rodebaugh, BS, Mercy Ministries Jeffrey Stone, PhD, Penn State University The patient is central to everything we do. Patient Safety complies with Jennifer Taylor, PhD, Drexel University the Patients Included™ journal charter, which requires at least two patient Carlos Urrea, MD, Hill-Rom members on the editorial board; regular publication of editorials, reviews, Linda Waddell, MSN, RN, Wolff Center at UPMC or research articles authored by patients; and peer review by patients. Eric Weitz, Esq., The Weitz Firm, LLC Margaret Wojnar, MD, MEd, Penn State College of Medicine This publication is disseminated quarterly by email at no cost to the sub- Zane R. Wolf, PhD, RN, LaSalle University scriber. To subscribe, go to patientsafetyj.com. ACKNOWLEDGMENTS PRODUCTION STAFF A special thanks to our reviewers: Regina M. Hoffman, MBA, RN, Editor-in-Chief Caitlyn Allen, MPH, Managing Editor Stephanie Baxley, MS, RD Eugene Myers, BA, Associate Editor Mark Bruley, BS Jackie Peck, BS, Layout Editor Regina Calla, MEd Shawn Kepner, MS, Data Editor Barbara M. Goldsmith, PhD, Jefferson Health Krista Soverino, BA, Graphics Becky Greenawalt, MA, Fulton County Medical Center Steven Gudowski, BS, RRT, Penn Medicine, Univ. of Pennsylvania Health System Marla Konas, BA, Lancaster Regional Medical Center EDITORIAL BOARD John McCafferty, MD, Einstein Heart & Vascular Inst. Joshua Atkins, MD, PhD, Hospital of the University of Pennsylvania Stephan McDonald, MSN, RN, ChristianaCare Russell Baxley, MHA, Beaufort Memorial Hospital Heidi A McMullan, MSN, WellSpan Philhaven Mark E. Bruley, BS, ECRI Institute (retired) Lisa Rodebaugh, BS, Mercy Ministries Michael A. Bruno, MD, Penn State Milton S. Hershey Medical Center Ronald Wyatt, MD, Cook County Health Michael R. Cohen, MS, RPh, Institute for Safe Medication Practices Daniel D. Degnan, PharmD, Purdue University School of Pharmacy Patient Safety Authority Barbara Fain, JD, MPP, Betsy Lehman Center for Patient Safety 333 Market Street - Lobby Level Kelly Gleason, PhD, RN, Johns Hopkins School of Nursing Harrisburg, PA 17101 Hitinder Gurm, MD, Michigan Medicine patientsafetyj.com Julia A. Haller, MD, Wills Eye Hospital [email protected] Jennifer Hamm, BS, Fred Hamm, Inc. 717.346.0469 Ann Hendrich, PhD, RN, Building Age-Friendly Health Systems, John A. Hartford Foundation; formerly Ascension Healthcare Together we save lives Patient Safety I September 2020 I 3 Contents September 2020 I Vol. 2, No.3 2 LETTER FROM THE EDITOR 42 PERSPECTIVES CHOKING EVENTS 6 FROM 18 HOLES TO 18 STEPS NEIL SIDRANE An avid golfer turned COVID survivor gets candid about his hospitalization while running a small “essential” business in New York and what it really means to be “recovered.” 54 ENGAGING PATIENTS IN THEIR CARE CAN BE A MATTER OF LIFE AND DEATH SUSAN WALLACE Pennsylvania Act 112 of 2018: Learn what it is and how it may one day save your life. 58 INTIMATE PARTNER VIOLENCE AND A PANDEMIC: WHAT HEALTHCARE WORKERS NEED TO KNOW BETHANY DAVIS When tallying the devastation caused by COVID-19, the hundreds of thousands of lives lost is only the beginning. 68 SCIENCE: THE NEXT GENERATION 54 CAITLYN ALLEN Meet Danielle Miller, a high school student from Enola, DIAGNOSTIC ERROR Pennsylvania, who offers hope for a brighter future. 71 DRAFTING SUCCESS: CREATING A NATIONAL ACTION PLAN FOR PATIENT SAFETY CAITLYN ALLEN While every patient, provider, and hospital is unique, we share more similarities than we realize. We sat down with Drs. Tejal Gandhi (IHI Senior Fellow) and Jeffrey Brady (AHRQ) to discuss their plan to reduce harm across the United States. 68 SCIENCE: THE NEXT GENERATION ORIGINAL ARTICLES 10 PROCESS FAILURES THAT INCREASE THE RISK OF INFECTION THROUGH RESPIRATORY DROPLETS: A 58 STUDY OF PATIENT SAFETY EVENTS REPORTED BY INTIMATE PARTNER VIOLENCE FACILITIES ACROSS PENNSYLVANIA AMY HARPER ET AL. While 2020 is the year of COVID, old faithfuls like influenza and pneumonia must not be forgotten. 24 AROUND THE WORLD IN 16 WAYS CAITLYN ALLEN AND SUSAN WALLACE Falls are among the most pervasive and difficult-to-eliminate patient safety challenges. Join the authors as they travel around the world seeking innovative strategies to prevent this age-old problem. 30 AN ANALYSIS OF NONSUICIDAL SELF-INJURY
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