orm_may-2024 - 22

Safety
years ago, barriers to accessible healthcare
still exist for people with disabilities.
People with disabilities are more
likely to experience higher
9
rates of
adverse health conditions, including
COVID-19; mental health concerns; and
abuse, violence, and neglect. People
with disabilities are also at greater risk
for health disparities related to diagnostic
overshadowing-an incorrect attribution
of symptoms to a major diagnosis.
Healthcare organizations must ensure
their processes and infrastructure
are sufficient to support clinicians in
providing equitable care for patients
with all types of disabilities, including
difficulties related to mobility, cognition,
hearing, vision, independent living, and
self-care. Start by creating an organizational
goal to promote disability-competent
healthcare values. Shared care
plans provide the opportunity to partner
with patients and their families, while
studying safety events fosters greater
understanding of contributing factors
(such as diagnostic overshadowing).
Delay in care resulting from drug,
supply, and equipment shortages
At a time when 93% of healthcare executives
report experiencing product
shortages, the healthcare supply chain
continues to struggle with the lingering
effects of the COVID-19 pandemic. Lack
of drugs, supplies, and equipment disrupts
the ability to meet patient needs
across the care continuum, often delaying
treatment and services, worsening
patient outcomes, and increasing costs.
To mitigate the impact at your fa8
cility,
take routine inventory of all critical
supplies and perform periodic risk
assessments to prioritize vulnerable
items. Leaders should ask for increased
transparency from manufacturers, group
purchasing organizations, or other suppliers
regarding source information and
alternative acquisition plans. Consider
shifting offshore suppliers to onshore,
nearshore, or friendly-shore manufacturers
to reduce the risk of disruption.
22
OR Manager | May 2024
Misuse of parenteral syringes
to administer oral liquid medications
ECRI's
affiliate ISMP continues to receive
reports describing patients who
were inadvertently given an oral liquid
medication intravenously. The unintended
administration of oral liquid
medications via the IV route can result
in serious consequences, including infection,
embolus with oral suspensions,
and even death. The risk of misadministration
can be reduced or eliminated
through consistent use of oral or enteral
syringes for preparation of small volume
oral/enteral liquids.
Organizations must maintain availability
of oral and/or enteral syringes
and educate staff on the importance of
using them for oral liquid medications.
For all serious safety events involving
parenteral syringes used for oral or enteral
medications, conduct a root cause
analysis that reviews both active and
latent contributing system factors. Create
an internal review and response
process for any concerns or reported
events regarding improper use of parenteral
syringes for administering oral
liquid medications.
10
Ongoing challenges with preventing
patient falls
Patient falls continue to be the number
one sentinel event reported to
Joint Commission. Potentially resulting
in serious harm or death, patient falls
may never be entirely eliminated within
healthcare settings. However, adherence
to protocols and interdisciplinary
approaches to caring for at-risk patients
can significantly decrease the frequency
of falls and the severity of resulting
injuries.
ECRI recommendations include creating
an interdisciplinary falls management
team to design and implement a
program including prevention practices,
data monitoring, fall risk assessments,
and continuous improvement activities.
Design a plan to engage patients and
families to become active partners in
developing fall prevention strategies.
Conduct purposeful rounding to assess
a patient's personal needs,
including
toileting and the desire to be out of bed
and mobilized if medically indicated.
Visit www.ecri.org/top-10-patientsafety-concerns-2024
to download the
full report for more detailed information
on practical strategies to mitigate the
harm associated with the 2024 top 10
patient safety concerns. ORM
-Heather David, MSN,
CRNP, AGACNP-BC, CSSYB,
is patient safety analyst
III at ECRI's Patient Safety
Organization, where she
assists members with patient safety
and quality improvement initiatives.
She is also a member of OR Manager's
editorial advisory board. Prior to joining
ECRI, she conducted patient safety
and performance improvement projects
for a large healthcare organization, including
causal analyses, assisting with
workplace violence prevention, and facilitating
healthcare-associated infection
reviews. A licensed acute care nurse
practitioner, David has nursing experience
in pediatrics and the perioperative
setting, including ENT/head and neck
surgery and thoracic surgery.
References
Brigance C, Lucas R, Jones E, et al.
Nowhere to go: maternity care deserts
across the US. (Report No. 3).
March of Dimes. 2022.
Bishop-Fitzpatrick L, Kind A J H. A
scoping review of health disparities
in autism spectrum disorder. Journal
of Autism and Developmental
Disorders. November 2017.
Common barriers to participation experienced
by people with disabilities.
Centers for Disease Control
and Prevention. September 16,
2020.
Executive Office of the President. A
Transformational Effort on Patient
www.ormanager.com
https://www.ecri.org/top-10-patient-safety-concerns-2024 https://www.marchofdimes.org/maternity-care-deserts-report https://pubmed.ncbi.nlm.nih.gov/28756549/ https://www.cdc.gov/ncbddd/disabilityandhealth/disability-barriers.html http://www.ormanager.com

orm_may-2024

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