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What’s New in the
Patient Safety World
November 2021
New Risk Factor for
Patient Safety Events:
Motor Vehicle
Accidents
Kudos to Elizabeth Kukielka and the Pennsylvania Patient Safety Authority for
uncovering a previously underrecognized risk factor for patient safety events –
motor vehicle accidents!
Kukielka analyzed reports of patient safety events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) related to motor vehicle crashes and identified 282 reports for analysis that occurred from 2018–2020 (Kukielka 2021). 13.1% of reports were classified as serious events (i.e., events that resulted in patient harm), a significantly higher percentage compared with that of the full acute care PA-PSRS database (2.9%). Most common were problems with monitoring or treatment (43.3%), problems with evaluation (18.4%), falls (11.7%), problems with documentation (7.4%), medication errors (7.4%), and problems with transfers (6.4%).
Kukielka notes that, when a patient who has experienced trauma in a motor vehicle accident presents to the emergency department, they may be unable to participate in their own care due to numerous factors, such as being unconscious, physically incapacitated, or suffering from confusion. In addition, her analysis showed other potential contributing factors:
- communication breakdowns
- lack of policies or protocols or unawareness about existing policies
or protocols for treating certain patient populations
- prioritization of conditions related to a motor vehicle crash over underlying health conditions
The latter category
included numerous reports where a patient with a known underlying condition did
not receive appropriate care for that condition while care for injuries
related to the motor vehicle crash were ongoing. Examples included a patient
with obstructive sleep apnea who did not receive treatment with CPAP or a
patient with diabetes was not prescribed basal insulin.
About a quarter of
the reports came from the emergency department. Kukielka
cites other studies which noted contributing factors such as unavailability or
limited access to key patient information, high workload, crowding, nonlinear
patient flow, and unclear responsibility for patient sign-out or follow-up.
This study is an
important contribution to the patient safety literature. It reveals both patient
and system vulnerabilities that have previously flown “under the radar”.
References:
Kukielka E. Safety Events Impacting Hospitalized Patients Following Motor Vehicle Crashes: A Qualitative Study of Reports from Pennsylvania Hospitals. Patient Safety 2021; 3(3): 18-27 September 2021
https://patientsafetyj.com/index.php/patientsaf/article/view/motor-vehicle-crash
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