An Analysis of Patient Safety Events Submitted by Abortion Facilities in Pennsylvania 2017–2019

Induced abortion, also called elective abortion, therapeutic abortion, and termination of pregnancy, is widely considered a safe procedure, but complications are known to occur. In Pennsylvania, an induced abortion may be performed at an abortion facility as an outpatient procedure, and these facilities are required to report patient safety events to the Pennsylvania Patient Safety Reporting System (PA-PSRS). We extracted 736 events submitted to PAPSRS by abortion facilities from 2017 through 2019 and analyzed these events in order to better understand patient safety concerns at abortion facilities in particular. All patients were female, and they ranged in age from 14 to 47 years, with a median patient age of 27 years (interquartile range = 23 to 31 years). Complications related to an induced abortion comprised the majority of events (71.6%; n=527), followed by unplanned transfers to the emergency department or acute visits to a healthcare facility following an induced abortion (13.9%; n=102). The most common complication associated with induced abortion was an incomplete abortion (i.e., retained pregnancy tissue; n=343); other complications included failed abortions (i.e., a continuing intrauterine pregnancy following an abortion; n=101), infections (e.g., endometritis and pelvic inflammatory disease [PID]; n=45), and surgical complications (e.g., hematometra, uterine perforation, and cervical lacerations; n=66). The remainder of events (14.5%; n=107) described other patient safety events that occurred at abortion facilities, such as documentation failures and medication-related events.

Development of a Taxonomy for Medication-Related Patient Safety Events Related to Health Information Technology in Pediatrics

Background Although electronic health records (EHRs) are designed to improve patient safety, they have been associated with serious patient harm. An agreed-upon and standard taxonomy for classifying health information technology (HIT) related patient safety events does not exist. Objectives We aimed to develop and evaluate a taxonomy for medication-related patient safety events associated with HIT and validate it using a set of events involving pediatric patients. Methods We performed a literature search to identify existing classifications for HIT-related safety events, which were assessed using real-world pediatric medication-related patient safety events extracted from two sources: patient safety event reporting system (ERS) reports and information technology help desk (HD) tickets. A team of clinical and patient safety experts used iterative tests of change and consensus building to converge on a single taxonomy. The final devised taxonomy was applied to pediatric medication-related events assess its characteristics, including interrater reliability and agreement. Results Literature review identified four existing classifications for HIT-related patient safety events, and one was iteratively adapted to converge on a singular taxonomy. Safety events relating to usability accounted for a greater proportion of ERS reports, compared with HD tickets (37 vs. 20%, p = 0.022). Conversely, events pertaining to incorrect configuration accounted for a greater proportion of HD tickets, compared with ERS reports (63 vs. 8%, p < 0.01). Interrater agreement (%) and reliability (kappa) were 87.8% and 0.688 for ERS reports and 73.6% and 0.556 for HD tickets, respectively. Discussion A standardized taxonomy for medication-related patient safety events related to HIT is presented. The taxonomy was validated using pediatric events. Further evaluation can assess whether the taxonomy is suitable for nonmedication-related events and those occurring in other patient populations. Conclusion Wider application of standardized taxonomies will allow for peer benchmarking and facilitate collaborative interinstitutional patient safety improvement efforts.

An Improved Comprehensive Medication Review Process to Assess Healthcare Outcomes in a Rural Independent Community Pharmacy

For years many pharmacists have been performing ‘brown bag’ medication reviews for patients. While most pharmacists and student pharmacists are familiar with this process, it is important to determine the value patients receive from this service. Over the course of this study the authors attempted to modernize the medication reconciliation process and collect data on patient prescription drug and over-the-counter drug use, along with quantifying the types of interventions the pharmacy’s clinical staff performed for patients during this process. The pharmacy partnered with a Quality Improvement Organization to trial their Blue Bag Intervention (BBI) program. The BBI program offered several additional services to the traditional brown bag review. The BBI was instituted as a follow-up tool in the pharmacy’s diabetes self-management education/training clinic to aid in patient follow-up and help the clinical staff identify medication-related events such as medication adherence issues and drug–drug interactions. The clinical staff identified approximately 2.2 events per patient with over 50% being issues that affected patient safety.

Contributing causes to adverse events in home care and potential interventions to reduce their incidence

The increasing complexity of home care services, pressures to discharge patients quicker, and the growing vulnerabilities of home care clients all contribute to adverse events in home care. In this article, home care staff in six programs analyzed 27 fall- and medication-related events. Classification of contributing causes indicates that patient and environmental factors were common in fall events, while organization and management factors along with patient, task, team, and individual factors were common in medication-related events. Home care settings create specific challenges in identifying and mitigating risks. Some factors, such as variations in home environments, are difficult to address. However, changing care coordination structures and communication methods could ameliorate other factors, including poor communications among staff and limited team and cross-sector communication and coordination. Ensuring that medication ordering and administration processes are optimized for home environments would also contribute to safer care.