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Harrisburg, PA 17120


Phone: 717-346-0469
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Follow-up on Previous Advisory Articles
PA PSRS Patient Saf Advis 2004 Dec;1(4):6. 
 

Insulin and Tuberculin Syringe Confusion

In an October 28, 2004, Supplementary Advisory (Vol. 1, Sup. 1), PA-PSRS informed Pennsylvania healthcare facilities about the risk of insulin overdose from confusion between insulin and tuberculin (TB) syringes. A hospital-based Patient Safety Officer contacted us to share his facility’s three strategies for dealing with this hazard:

  1. They order only orange insulin syringes and green TB syringes.
  2. They print their insulin order set in orange to reinforce with staff the association between orange color-coding and insulin products.
  3. They physically separate insulin and TB syringes in all supply rooms and enhance the markings on each storage bin.

“Time Out”

The September 2004 Advisory (Vol. 1, No. 3) discussed the topic of pausing for verification of a patient’s identity, procedure, operative site, position, and special needs. Two Patient Safety Officers have given PSRS feedback about improvements they have made in their “time out” process that may be of interest to other facilities.

One hospital recognized that some procedures, such as anesthetic blocks for relief of pain, are done by a single provider. Their “time out” policy includes a requirement that an individual doing a procedure alone get another provider to participate in the time out, just as a nurse transfusing a unit of blood would get another provider to verify the correct match of patient and blood before starting a transfusion.

Another hospital is doing an “extended” time out, which includes not only the standard identification of the patient, procedure, site, and position, but also a review of the patient’s allergies and comorbid conditions and a check to ensure that all equipment to be used in the procedure is functioning properly.
 
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Follow-up on Previous Advisory Articles
Insulin and Tuberculin Syringe Confusion
“Time Out”



THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS  
PSA LOGO The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .      
ECRI LOGO ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.      

ISMP Logo The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.      
 
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