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Download Download PATIENT SAFETY December 2019 | Vol. 1, No.2 What’s Your One Thing? How one boy changed patient safety How One Coalition Analyzing Telemetry Leveraging Trigger Transformed Care in Monitoring Errors: Tools to Identify Camden, NJ, Seven Learn the Risks Medication Errors Days at a Time ABOUT PATIENT SAFETY Matthew Keris, Esq., Marshall, Dennehey, Warner, Coleman & Goggin Stephen Lawless, MD, Nemours Children’s Health System As the journal of the Patient Safety Authority, committed to the Michael Leonard, MD, Safe & Reliable Healthcare, LLC LETTER vision of “safe healthcare for all patients,” Patient Safety (online James McClurken, MD, Doylestown Health, Lewis Katz School of From the Editor ISSN 2641-4716) is fully open access and highlights original Medicine at Temple Univ. research, advanced analytics, and hot topics in healthcare. Patrick J. McDonnell, PharmD, Temple Univ. School of Pharmacy The mission of this publication is to give clinicians, administra- Dwight McKay, BSL, Lancaster Rehabilitation Hospital tors, and patients the information they need to prevent harm and Ferdinando L. Mirarchi, DO, UPMC Hamot improve safety—including evidence-based, original research; edi- Dona Molyneaux, PhD, RN, Thomas Jefferson University Hospital through this journal and many Pennsylvania that cause high torials addressing current and sometimes controversial topics; and Gina H. Moore, BSN, RN, Christiana Care Health Services other initiatives to make care harm and death to patients. analysis from one of the world’s largest adverse event reporting Rustin B. Morse, MD, Children’s Health System of Texas safer for others. And finally, Sara Kolc Brown and databases. Adam Novak, MA, Michigan Health & Hospital Association Barbara Pelletreau, RN, MPH, Dignity Health co-authors share one facility’s Our December issue features We invite you to submit manuscripts that align with our mis- Julia C. Prentice, MSPH, PhD, Betsy Lehman Center for Patient Safety a patient perspective piece by initiative to decrease adverse sion. We’re particularly looking for well-written original research Mitesh Rao, MD, MHS, Stanford School of Medicine drug events by using trigger articles, reviews, commentaries, case studies, data analyses, qual- Cheryl Richardson, MPH, RN, Penn State Milton S. Hershey Med. Center Kristin Aaron, who shares the ity improvement studies, or other manuscripts that will advance tools. Their work contributes Lisa Rodebaugh, BS, Mercy Ministries tragic healthcare journey of her patient safety. Jeffrey Stone, PhD, Penn State University to further development of son, Jenson (featured on our All articles are published under the Creative Commons Attribution Jennifer Taylor, PhD, Drexel University prevention strategies. cover), and how great change – Noncommercial license, unless otherwise noted. The current Carlos Urrea, MD, Hill-Rom Linda Waddell, MSN, RN, Wolff Center at UPMC often starts with a single step. I never imagined that one of issue is available at patientsafetyj.com. Eric Weitz, Esq., The Weitz Firm, LLC Our back inside cover features the most difficult tasks in the The patient is central to everything we do. Patient Safety complies Margaret Wojnar, MD, MEd, Penn State College of Medicine The Walking Gallery jacket publication process would be with the Patients Included™ journal charter, which requires at least Zane R. Wolf, PhD, RN, LaSalle University #160 Cancer for Christmas. selecting the papers to feature two patient members on the editorial board; regular publication of editorials, reviews, or research articles authored by patients; and Casey Quinlan, diagnosed with on our cover. There are so peer review by patients. ACKNOWLEDGMENTS breast cancer just days before many that equally deserve A special thanks to our reviewers: This publication is disseminated quarterly by email at no cost to Christmas in 2007, leveraged the spotlight. I hope this will the subscriber. To subscribe, go to patientsafetyj.com. Mark E. Bruley, BS, ECRI Institute (retired) her experience to help others continue to challenge me with Michael R. Cohen, RPh, MS Institute for Safe Medication Practices navigate cancer treatment. each issue. The information, Deborah A. Cruz, MSN, CRNP, Jefferson Health PRODUCTION STAFF Quinlan was a charter author for achievements, risk reduction Marjorie Funk, PhD, RN, Yale School of Nursing Regina M. Hoffman, MBA, RN, Editor-in-Chief Trenya Garner, MPA, Children’s Hospital of Philadelphia Patients Included™, a nonprofit strategies, lessons learned, Caitlyn Allen, MPH, Managing Editor Matthew Grissinger, RPh, Institute for Safe Medication Practices inspiring organizations to and individual perspectives are Eugene Myers, BA, Associate Editor John Gottsch, MD, Johns Hopkins include patients in their work. I integral pieces to improving Jackie Peck, BS, Layout Editor Leslie Hyman, PhD, Wills Eye Hospital Shawn Kepner, MS, Data Editor am proud to say Patient Safety is patient safety for all. This journal Mark Jarrett, MD, MBA, MS, Northwell Health Benjamin Kohl, MD, Jefferson Health a Patients Included™ publication. is one avenue to share these Adam J. Krukas, PharmD, MSHI, National Center for Human EDITORIAL BOARD Also from our cover: Cait valuable resources freely with Factors in Healthcare Regina Hoffman, others. If you have research, Joshua Atkins, MD, PhD, Hospital of the University of Pennsylvania Patrick J. McDonnell, PharmD, Temple University School of Allen, director of engagement Russell Baxley, MHA, Beaufort Memorial Hospital Pharmacy Editor-in-Chief improvement initiatives, or Patient Safety and managing editor with the Mark E. Bruley, BS, ECRI Institute (retired) Rustin Morse, MD, Children’s Health Patient Safety Authority, sat perspectives that contribute to Michael A. Bruno, MD, Penn State Milton S. Hershey Medical Center Chirag Shah, MD, MPH, Ophthalmic Consultants of Boston Michael R. Cohen, RPh, MS Institute for Safe Medication Practices Rachele Wilson, DVM hank you to every reader, down with Kathleen Noonan, our collective knowledge, please consider submitting your next Daniel D. Degnan, PharmD, Purdue University School of Pharmacy Margaret Wojnar, MD, MEd, Penn State College of Medicine author, reviewer, editorial chief executive officer of the Barbara Fain, JD, MPP, Betsy Lehman Center for Patient Safety board member, and staff manuscript to Patient Safety at T Camden Coalition of Healthcare Kelly Gleason, PhD, RN, Johns Hopkins School of Nursing Patient Safety Authority person for making the launch Providers, to talk about some patientsafetyj.com. Hitinder Gurm, MD, Michigan Medicine 333 Market Street - Lobby Level Julia A. Haller, MD, Wills Eye Hospital of Patient Safety a success. In innovative solutions to meet Wishing you and yours the most Harrisburg, PA 17101 Jennifer Hamm, BS, Fred Hamm, Inc. patientsafetyj.com a short period of time, nearly the needs of a very at-risk joyous holiday season! Ann Hendrich, PhD, RN, Building Age-Friendly Health Systems, John [email protected] 7,000 people from over 120 population. Elizabeth Kukielka A. Hartford Foundation; formerly Ascension Healthcare 717.346.0469 countries and all 50 United and co-authors discuss the Mark Jarrett, MD, MBA, MS, Northwell Health States read the inaugural issue. findings of a database analysis I also extend a special thanks to related to telemetry monitoring; our patient representatives, who this article was inspired by dedicate their time and energy a deep dive into events in Together we save lives 2 I PatientSafetyJ.com I December 2019 Patient Safety I December 2019 I 3 Contents December 2019 I Vol. 1, No.2 2 LETTER FROM THE EDITOR 45 NEWBORN FALLS ELIZABETH KUKIELKA AND SUSAN WALLACE Newborn falls are rare occurrences—or are they? A PERSPECTIVES review of data from the nation’s largest event reporting database reveals they may be more common than you 6 PATIENT PERSPECTIVE think. 12 KRISTIN AARON 1460 Allergy-Related HEALTHCARE10 VIOLENCE Cancer was just the beginning for 2-year-old Jenson INFUSION PUMPS 54 DATA SNAPSHOT: FALLS Medication Errors Aaron. His mother, Kristin, shares his battle with a rare SUSAN WALLACE AND CAITLYN ALLEN illness; the effects of contracting multiple healthcare-ac- One in 56 patients fall every year in Pennsylvania quired infections; and how her family overcame tragedy hospitals. See the breakdown by age, harm score, to make a lasting, measurable difference. and patient days. 12 VIOLENCE AGAINST HEALTHCARE WORKERS 60 RISK OF MEDICATION ERRORS WITH REGINA HOFFMAN Assault rates in hospitals this year were the highest on INFUSION PUMPS record. Yet, despite bipartisan support, legislative pro- MATTHEW TAYLOR AND REBECCA JONES tections across states is inconsistent. How can we ensure Every day in every hospital, infusion pumps deliver violence against healthcare workers is a never event? vital medications and nutrients to patients. But what happens when these lifesaving devices stop working? 82 ONE-ON-ONE: KATHLEEN NOONAN Camden, New Jersey—when most people were dismiss- PATIENT SAFETY INITIATIVES ing it as the “Murder Capital of America,” a group of providers saw an opportunity. Seventeen years later, 70 SUICIDE PREVENTION CHRISTOPHER MAMROL AND OTHERS the Camden Coalition has proven that when hard work What do IV pumps, clocks, and faucets have in common? and ingenuity are mixed with the right blueprint, lasting They’ve all been used as ligature points in attempted success can happen anywhere. 70 suicides. Think you know all the risks? Read about 10 the Patient Safety Authority’s 2018 keystone project
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