PATIENT SAFETY journal articles, upcoming webinars & more

What You Need to Know

This special edition of our newsletter features articles, stories, interviews, and more from the most recent issue of our journal, Patient Safety, as well as details about our upcoming events and webinars.

The Challenges of Transition to Practice Expressed Through the Lived Experience of New-to-Practice Nurses

Are we adequately preparing nurses to enter the workforce? Toothaker et al. interviewed 11 nurses in their first six months following graduation about their personal experiences and struggles in transitioning from school to practice. They shared some common themes and challenges, including a lack of practical knowledge, feelings of impostor syndrome, concerns about the safety of workers and patients, and internalized fear. The stories and data the researchers collected suggest solutions may lie in enhancing the academic curriculum, better mentoring, and nurse residency programs.

RISE and Shine: How Jefferson Health’s Peer Support Program Improves Care for All

Evidence suggests that providing psychological support to caregivers can make care safer. Such is the basis for Jefferson Health’s RISE program: peer-to-peer mentoring for providers involved in patient harm. Program leads, John Olsen and Dr. Scott Cowan, sat down with Patient Safety managing editor, Caitlyn Allen, to discuss the program’s genesis, the positive impact it’s had on staff, and how the program can be replicated in other institutions.

2021 Pennsylvania Patient Safety Reporting: Updated Rates for Acute Care Event Reports

In the article we published in June 2022 on patient safety trends in 2021, reporting rates and fall rates for 2021 were calculated based on Q1 and Q2 only, as denominator data for Q3 and Q4 were not yet available. Given that the COVID-19 pandemic has disrupted reliable forecasting in healthcare, we did not forecast rates for Q3 and Q4 in our June 2022 article. This data snapshot provides the complete rates for 2021 now that we have obtained all relevant data.

Patient Safety Alert: Air Embolism During Cardiac Ablation

During a cardiac ablation procedure, the catheter irrigation fluid bag emptied and was replaced by staff. While priming the tubing, air was noted in the tube, and the catheter was immediately removed from the patient. The patient experienced a decrease of heart rate and blood pressure requiring a code response.

Radiofrequency cardiac ablation requires the use of heparinized irrigation fluid to cool and anticoagulate the ablation site. If the procedure requires more fluid than originally hung, it requires the bag to be replaced. This introduces an opportunity for air to enter the irrigation tubing. Air emboli can then be infused into the patient, causing cardiac arrhythmia, myocardial infarction, respiratory symptoms, and/or neurologic symptoms, and, potentially, total cardiovascular collapse.

Improving Communication From Hospital to Skilled Nursing Facility Through Standardized Hand-Off

Communication during patient hand-off from one caregiver or facility to another is crucial to ensure the patient continues to receive timely and appropriate treatment. This is especially true when a patient is discharged from a hospital to a skilled nursing facility (SNF), as this patient population is prone to functional and clinical decline. Studies show that SNFs often receive incomplete and inaccurate patient information before transition, leaving nurses unprepared and delaying critical medications for 24 hours.

To improve communication from hospital to SNF, Baluyot et al. identified problems in patient hand-offs and developed a standardized hand-off tool and training that decreased the wait time for controlled medication prescriptions by 79%, with an associated 52.9% reduction in late administration, and decreased wait time for intravenous antibiotics by 94%, with a 77.8% reduction in late administration. Read more about this quality improvement project and standardized hand-off tool.

Onward and Upward: The Future of Nursing Education

As nurses around the globe battled COVID, one inconvenient truth became glaring: There were not enough nurses to provide care. And those shortages will only get worse. Now that we have emerged from the pandemic, nurse educators have become more important than ever. What does future curricula look like? How can technology augment training and staffing? How can we ensure the next generation of nurses is dynamic enough for whatever might come their way? Patient Safety managing editor, Caitlyn Allen, sat down with Cedar Crest College senior instructor Eileen Fruchtl to learn more.

Healthcare in Prison: An Inside Look

Often depicted in films and television, much of what the general population knows about prison—particularly the infirmaries—comes from Hollywood. Patient Safety managing editor, Caitlyn Allen, sat down with Erica Benning, Bureau of Healthcare director for the Pennsylvania Department of Corrections, to discuss healthcare delivery for almost 40,000 incarcerated individuals: what can be done in-house, how her team handles inmates with mental illness, their COVID response, and more.

A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veterans Affairs Medical Center

Anesthetized patients awakening from a surgical procedure may be disoriented and engage in dangerous behavior, such as kicking, punching, and attempting to exit the bed or operating table. This temporary condition is called emergence delirium, and there are several factors that increase a patient's risk of experiencing it, including post-traumatic stress disorder.

To address this challenge and better protect their patients and staff, a multidisciplinary team at Veterans Affairs Pittsburgh Healthcare System developed and implemented an intervention that incorporated training and 21 clinical components. Read about how their initiative substantially reduced the occurrence and severity of ED, ED-related patient and staff injuries, and ED-related loss of intravenous access and airway patency—and download the tools they used to replicate their success.

WEBINAR • 1/17/23 (11:30 a.m. –12:30 p.m.)

Pharmacists' Role in Patient Safety—More Than Meets the Eye

Pharmacists play a critical role in patient safety by serving as an information source to staff and patients, evaluating medication suitability, identifying potential adverse effects, and promoting medication adherence.

Please join Megan Scheid, PharmD, medication safety officer at Reading Hospital of Tower Health; Jennifer Kunkel, PharmD, medication safety officer at Jefferson Health-Abington; and Christopher Walsh, PharmD, medication safety pharmacist at Penn State Health St. Joseph Medical Center, as they discuss strategies their institutions have implemented to best leverage this key member of the care team.

1.0 continuing education hours will be awarded for completion of this webinar. Continuing education credits apply to Pennsylvania registered nurses only.

Do you often feel there must be more to the puzzle after an event occurs, but you’re not sure where to find additional pieces? Attend our Outside the Box webinar series to learn how to gather information from unlikely sources.

1.0 continuing education hours will be awarded for the completion of each individual module listed above. Continuing education credits apply to Pennsylvania registered nurses only.

January 26, 2023 – 12 to 1 p.m.

Title: Outside the Box Webinar Series: Billing Data, ICD-10 Codes

Registration Link: https://papsa.webex.com/weblink/register/r8efc0d8ea0d526777240c249efec7a22

February 16, 2023 – 12 to 1 p.m.

Title: Outside the Box Webinar Series: Patient Reporting Systems, Complaints

Registration Link: https://papsa.webex.com/weblink/register/rd08dec6dec37df69bb2a894c7d96dc38

March 30, 2023 – 12 to 1 p.m.

Title: Outside the Box Webinar Series: Audits, Chart Reviews, Trigger Tools

Registration Link: https://papsa.webex.com/weblink/register/rb1cf3c6b29dd68105bff36b2906457a3

April 27, 2023 – 12 to 1 p.m.

Title: Outside the Box Webinar Series: Medication Technology, Smart Pumps, BCMA, and ADCs

Registration Link: https://papsa.webex.com/weblink/register/r6b2252e86afe2b33bbac77c5e54df294

May 18, 2023 – 12 to 1 p.m.

Outside the Box Webinar Series: Media and Publications

Registration Link:

https://papsa.webex.com/weblink/register/r116295ebf2a357c01007e2fe4b6b5d75

Antibiotic resistance is an increasing problem in healthcare, especially in nursing homes, where up to 75% of antibiotics are prescribed inappropriately. Contributing to this is pressure from residents and families, antiquated prescribing practices, and a “What could it hurt?” mentality.

Whether you need to rebuild your antibiotic stewardship program from scratch or just want to make sure all the basics are covered, sign up for our Antibiotic Stewardship Webinar Series! Participants will receive an overview of antibiotic stewardship, assistance in evaluating current policies/processes, and tools to develop an effective program.

.50 continuing education hours will be awarded for the completion of each individual module listed above. Continuing education credits apply to Pennsylvania registered nurses only.

February 9, 2023 – 12:30 to 1 p.m.

Title: Antibiotic Stewardship Webinar Series: Why Antibiotic Stewardship and who Should be at the Table

Registration Link: https://papsa.webex.com/weblink/register/r0da4f1e0ffc396f2b4b3d6519558d5de

March 9, 2023 – 12:30 to 1 p.m.

Title: Antibiotic Stewardship Webinar Series: Types of Antimicrobials

Registration Link: https://papsa.webex.com/weblink/register/r8998ba3d3a0b6862f8f09779782551a8

April 13, 2023 – 12:30 to 1 p.m.

Title: Antibiotic Stewardship Webinar Series: Antimicrobial Usage

Registration Link: https://papsa.webex.com/weblink/register/r0e64bc6fd0f3caf312b9184c46043058

May 11, 2023 – 12:30 to 1 p.m.

Title: Antibiotic Stewardship Webinar Series: Mechanisms of Antimicrobial Resistance (MDROs, Susceptibilities)

Registration Link: https://papsa.webex.com/weblink/register/r571e0da3039907335a469471d1b11457

June 8, 2023 – 12:30 to 1 p.m.

Title: Antibiotic Stewardship Webinar Series: Antibiograms

Registration Link: https://papsa.webex.com/weblink/register/r3f621322073bf9de5417a30c09f1ada1

July 13, 2023 – 12:30 to 1 p.m.

Title: Antibiotic Stewardship Webinar Series: Antimicrobial Baseline Data

Registration Link: https://papsa.webex.com/weblink/register/r67e05ca50732629318196b8d245621da

August 10, 2023 – 12:30 to 1 p.m.

Title: Antibiotic Stewardship Webinar Series: Antibiotic Stewardship Plan

Registration Link: https://papsa.webex.com/weblink/register/r88399004ed53c2eb93fdbd3cc6e1db59

September 14, 2023 – 12:30 to 1 p.m.

Title: Antibiotic Stewardship Webinar Series: Clinical Decision-Making

Registration Link: https://papsa.webex.com/weblink/register/r26290314c254c6b54f35b58379a34432

October 12, 2023 – 12:30 to 1 p.m.

Title: Antibiotic Stewardship Webinar Series: Antimicrobial Usage Data

Registration Link: https://papsa.webex.com/weblink/register/r3159506bf682cbd76a222851b444f58e

This communication is intended to support reporting facilities and patient safety programs in their work with the Patient Safety Authority. If you feel you have received this email in error, please contact the PSA before clicking "Unsubscribe" below.