Page 74 - Flipbook January Board

Patient Safety Update- BQI - January 2019

Patient Safety Committee Report:
Confidential: Peer Review Protected
RPH: PA-PSRS State Reportable Events
September- November 2018 Events*

All Harm All Harm All Harm
Scores Scores Scores
September October November
Event Type 2018 2018 2018
Medication Error 11 14 8

Adverse Drug Reactions 9 8 7
Equipment / Supplies /Devices 2 2 1

Fall 21 16 11
Error related to Procedure / Treatment / Test 26 29 11

Complication related to Procedure / Treatment / 9 5 3
Test

Transfusion 2 0 2
Skin Integrity 5 3 4
Patient Self Harm (new as of April 1 ) 0 1 1
st
Other / Miscellaneous 57 28 40
Emergency Services / Response 0 1 0

Physical Plant / Utilities / Service Disruption 1 3 6
Administration / Management 1 1 0
Medication Safety 0 0 0

Criminal / Potentially Criminal or Illegal Activity 3 1 1
Capacity/Infrastructure Failure 43 49 50

Infections (via NHSN) 9 12 9
Total 199 173 153

Serious Events: November-1
• 4W- Fall with injury. 4cm laceration to back of head that needed 6 staples. RCA
completed.

NHSN – Infections:
• 1SSI-Organ/space infection from General Surgery Whipple procedure
• 1 SST- (skin/ soft tissue infection)- 2ICU