PSRS reports are a rich source of information from the VA’s “front lines” about efforts to improve patient care. In many cases, they provide “snapshots” of problems that may be experienced at VA facilities. Our “snapshots” in this issue highlight some challenges, as well as the ideas, fixes and suggestions that the reporters were willing to share with PSRS. The topics of interest focus on infectious diseases, call lights, medication withdrawal schedules, and room number signage, including reporters’ suggestions for remedies of the accompanying hazards.

Zooming in on Infectious Diseases

A Registered Nurse, concerned about the risks of cross-contamination from infectious patients, recommended that a computerized alert be added for patients needing isolation.

• Reviewing patient’s notes, [I] see that doctor or infectious disease doctor has recommended patient be placed in isolation. This frequently is not communicated to nursing staff...Staff and visitors are being exposed...With an increase in...communicable disease, I feel we could implement further prevention, especially if we know an individual is at risk, or has an increased ‘probability.’...My suggestion would be some type of alert box for quick identification in CPRS. I believe this would help staff make needed arrangements [to] decrease risk of cross-contamination.

During a callback conversation with this reporter, it was stated that recommendations for isolation are being put in the general progress notes.  These are often missed by nurses. Patients with suspected TB and Hepatitis, for example, are not isolated and the tests are positive 2-3 days later when the staff realizes they have been exposed.  The reporter is going to the next Performance Improvement Committee meeting and suggest they look at this issue for their next facility-wide project.

Related Reference: Chiarello, L., Jackson, M., Rhinehart, E., & Siegel, J. (2007). 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Centers for Disease Control and Prevention, 43-62. Retrieved on July 08, 2008, http://www.cdc.gov/ncidod/dhqp/gl_isolation.html.

You Forgot the Flash

A Registered Nurse at a VA Long Term Care facility described an experiment that remedied malfunctioning patient call lights.

• Patient call lights are very old and not in proper working order. The technician has requested a new replacement over the past 6 months because of the outdated equipment. This is a patient hazard.

During the callback, the reporter stated the patient was on bedrest yet came out into the hall to summon the nurse.  These call lights might go off when pushed on, flicker, or go on when in the off setting. The nursing staff has to compensate for these malfunctions by making more frequent rounds to see what is really happening with their patients and may miss something important with the patient.  Engineers have replied that there are no plans to have a state-of-the-art call system at their new facility.  The reporter expressed concerns that if repairs are not done immediately, or a new system purchased, patient safety incidents will increase.  Suggestions to install a wireless system on the unit temporarily were submitted to the administrative level for consideration.

Are You Sure You Want to Delete This?

A Risk Manager learned of a severe withdrawal reaction after a patient discontinued Venlafaxine (Effexor). This PSRS reporter suggested an enhancement to the pharmacy computer program to prevent such events in the future.

• [Patient] with Post Traumatic Stress Syndrome was receiving a prescription for Effexor 300 mg. daily. He moved out of the country. He informed his provider that he was moving. His provider discontinued his prescriptions. The drug manufacturer cites several reported incidents of severe reactions to withdrawal of the drug. It also published a ‘withdrawal’ schedule....The patient alleged that he did have severe withdrawal. Recommended action: Suggest that an alert be added whenever Effexor is discontinued, to consider the withdrawal schedule. This could potentially have implications for all facilities that dispense Effexor with electronic order entry.

Related Reference: Physicians’ Desk Reference. (61st ed.). (2007). Montvale, NJ: Thomson PDR, p. 3413.

Focus on Numbers

A recent PSRS report suggests an alternative to plastic room number plaques that may be used by suicidal patients to harm themselves.

• A suicidal patient was admitted to the lockable inpatient psychiatric unit. This patient had a history of [self-inflicted injury]. [The] patient broke off a small metal piece left from where a room number plaque had been removed. The Nurse Manager suggested that rather than use plastic room number plaques which can be forced off the wall and broken providing a sharp edge to be used for harm, that the room numbers be stenciled onto the wall for all rooms in the inpatient locked [unit] or lockable hallway.