Bold Voices - May 2012 - (Page 9)

AT THE BEDSIDE Adverse Events Unreported infections, such as a case of septic shock leading to Hospital staff fail to report 86 percent of “adverse death; and medication-related events, such as four cases events” in medical care, partly because of misperceptions of excessive bleeding because of the administration of about what constitutes patient harm, notes the Department blood-thinning medication that also led to death.” of Health and Human Services. Nurses did the most reporting, bringing to light 31 of the “Hospital Incident Reporting Systems Do Not Capture 40 reported events. “Nurses most often identified events Most Patient Harm,” released by the Office of Inspector through patient observations and routine hospital safety General, finds that of 293 adverse events experienced by assessments,” the report notes. a sample of Medicare beneficiaries Nurses most often The report recommends that the in 2008, incident-reporting systems Centers for Medicare & Medicaid captured only 40, about 14 percent. identified and reported Services and the Agency for The other 86 percent fell through the adverse events. Healthcare Research and Quality cracks. develop a master list of potentially A related Medscape article notes reportable events to eliminate confusion about what constithat 62 percent of the adverse or temporary harm events tutes patient harm. It also suggests the agencies provide went unreported because staff did not consider them technical assistance to hospitals in using the list. reportable, according to hospital administrators. The What is your unit’s experience reporting adverse others “were ones that hospital staff commonly reported events? Tell us at, click on the but in these cases did not.” blue auto-reply button in the digital edition or leave a wall The report adds that “serious events not captured by comment at incident reporting systems included hospital-acquired Webinar: Nine Tips for Safe Multiple IV Medication Infusion Nine tips on how to safely administer multiple intravenous (IV) medications will be the focus of a free webinar Wednesday, May 30, 2-3 p.m. ET. The webinar targets nurses, practice leaders, educators, clinical managers, those responsible for medical equipment purchase decisions and senior hospital management. Multiple IV medications are often delivered with large-volume pumps through a combination of primary and secondary “piggyback” infusions on multiple pumps and channels. This complexity makes multiple IV medication infusions prone to errors that include physical line setup errors and mix-ups of infusion lines, bags and pumps. For a patient, this could mean an incorrect dose at the Smart pumps help reduce IV medication administration errors. wrong time with harmful consequences. Offered by AAMI Foundation’s Healthcare Technology Safety Institute, Arlington, Free May 30 webinar Va., Infusion Nurses Society, Norwood, Mass., and ISMP Canada, participants will learn how to identify and mitigate safety risks associated with administration of for clinicians and multiple IV infusions. others targets most Register for the free webinar at For further information, email or call (703) 253-8297. frequent errors. AACN BOLD VOICES MAY 2012 9

Table of Contents for the Digital Edition of Bold Voices - May 2012

Front/Digital Edition Viewing Guide
Another Angle
AACN Boards and Contact Information
Your NTI Checklist
AACN, Case Western Reserve University Announce Innovative DNP, PhD Collaboration
Patients at End of ICU Rounds Receive Less Face Time
Medical Panel Members Have Conflicts of Interest
Adverse Events Unreported
Penn Nursing Study: Nurse Burnout a Worldwide Problem
Low-Cost Changes to Nurses' Work Environment Also Benefit Patients
Hospital Workers Reluctant to Report Medical Errors
Flame of Excellence Awards
Circle of Excellence Awards
UTI Prevention Lower Priority Than Other HAIs
Children at Higher Risk for Infection in Intensive Care
Cameras, Feedback: Effective Tools to Enforce Hand Washing
In Our Journals
More Coronary Events Associated With Dabigatran
Certification Capsules
Publishing-related Events at NTI
Stay Connected at NTI
From the President

Bold Voices - May 2012