Pennsylvania Patient Safety Advisory Successful Reduction of Healthcare-Associated MRSA Infection Rates Introduction In Pennsylvania, some healthcare systems have suc- Approximately 70% of healthcare-associated infec- cessfully implemented system-based strategies to tions (HAIs) in the United States are caused by achieve cultural change. This article discusses two antibiotic-resistant bacteria such as methicillin-resis- healthcare systems that have reduced and sustained a tant Staphylococcus aureus (MRSA), which is one of the reduction in MRSA-related HAIs. most predominant and virulent pathogens in health- care today. The Centers for Disease Control and The VA Pittsburgh Healthcare System Prevention (CDC) estimates that more than 126,000 The VA Pittsburgh Healthcare System (VAPHS) is hospitalized patients are infected with MRSA annu- an integrated three-division system consisting of 692 ally, with approximately 5,000 deaths. Hospitalized operational beds serving a veteran population of more MRSA patients experience an increased length of stay than 58,869 unique patients. Services include acute approaching 9.1 days, associated with roughly $30,000 care, long-term care, and behavioral health, as well in additional costs per patient infection.1 Data from a as tertiary services such as cardiac surgery and solid study conducted by Davis et al. revealed that approxi- organ transplantation. mately 19% of patients with MRSA colonization at In October 2002, VAPHS made a firm commitment admission and 25% who acquire MRSA colonization to reducing HAIs. Its initiative, “Getting to Zero,” during hospitalization actually become infected.2 was developed with the goal of MRSA prevention. During 2006, the Association for Professionals Working in partnership with the Pittsburgh Regional in Infection Control and Epidemiology (APIC) Healthcare Initiative and CDC, VAPHS designed conducted a national MRSA prevalence study on and implemented the MRSA Prevention Initiative. A inpatients at U.S. healthcare facilities. The results number of principles based on the Toyota Production suggest that approximately 70% of MRSA isolates System (TPS) (see “The Toyota Production System were most likely acquired in the hospital rather than Approach”) were incorporated to identify specific brought in from the community.3 organizational structures and processes related to The Pennsylvania Health Care Cost Containment HAI and MRSA transmission.7 The primary aim was Council released a research brief in August of 2006, to transform the organizational culture to improve highlighting the incidence of MRSA in Pennsylvania compliance with hand hygiene and isolation pro- hospitalizations for 2004. While the data does not cedures and thus reduce MRSA transmission and distinguish between community-acquired and health- infection. The MRSA Prevention Initiative was care-associated infections, it does provide an in-depth initially implemented with dedicated supportive nurs- look at the issues related to MRSA in the hospital ing and educational resources on a 36-bed general setting throughout the state. The brief includes data surgical unit over a four-year period, expanding to on hospitalizations with MRSA by body system, sum- an 11-bed surgical intensive care unit in 2003, and marized by condition, age group, and geographic followed by facilitywide implementation in 2005. location. The MRSA infection rate for 2004 was simi- Support from the medical center’s executive team was lar in hospitals of all sizes.4 critical in achieving the goals. Key content and proce- dural strategies were identified using evidence-based An article in the December 2007 Pennsylvania Patient guidelines proposed by the Society for Healthcare Safety Advisory discusses the fact that prompt identifi- Epidemiology of America, APIC, and CDC.8 cation and effective communication of the status of patients may result in a reduction of MRSA.5 The following strategies were implemented and maintained: A number of U.S. healthcare facilities have sig- ■ MRSA surveillance cultures were obtained. Nares nificantly reduced rates of MRSA transmission and associated infections. Success in transferring best prac- swabbing was conducted on every patient on tices to and replicating positive changes in other units admission, discharge, or transfer, followed by or hospitals has been limited. In contrast, for more notification to the unit staff in a timely fashion of than two decades, MRSA infections have been signifi- positive results. cantly reduced or even eradicated in several European ■ Prompt isolation precautions were instituted, healthcare systems, compared to a far smaller number which were applicable to staff and visitors. Con- of U.S. healthcare facilities.6 These European coun- tact precautions were initiated for colonized and tries achieved success through implementation of infected patients. This included wearing gowns aggressive programs such as transmission-based con- and gloves when providing care and masks if the trol policies that included active surveillance cultures patient had MRSA pneumonia. Visitors were also to identify colonized patients followed by strict isola- instructed to adhere to hand hygiene protocols on tion precautions for those patients. These contrasting entry and exit to the patient’s room but were not results likely represent a difference in culture rather required to wear gowns and gloves. Red tape was than a knowledge deficit. strategically placed on the floor in the patient’s Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 27 Pennsylvania Patient Safety Advisory room to alert staff and visitors that contact precau- on the units and performed visual observation of tions were in place. hand hygiene practices. ■ Weekly MRSA briefings were conducted, which ■ Executive management support for resources included the executive team, unit staff (e.g., (equipment and supplies) was obtained. nursing environment management), and infec- ■ Systems for terminal cleaning of all the patient’s tion prevention and control, to share the unit’s rooms and adequate disinfection of shared equip- successes and to identify resources and barriers ment were implemented. needing administrative intervention. ■ Formal reporting of MRSA and HAI transmission ■ Aggressive hand hygiene protocols before and after rates to staff and hospital management was main- patient contact were instituted. A hospitalwide tained. education campaign on hand hygiene was devel- ■ Ancillary departments such as physical therapy oped for the benefit of staff and visitors. Posters were provided with updated lists of colonized/ were visibly placed on each unit. infected patients for the purpose of appropriate ■ Barriers to hand hygiene were removed. Alcohol scheduling of patients to prevent transmission. handrub dispensers were placed at the entry/exit of The ultimate goals of this initiative were realized patient rooms and other staff-identified locations. through changing workflow patterns, eliminating ■ Staff were provided with hand hygiene training impediments to compliance with established infection in the form of in-services and online tutorials to prevention and isolation procedures, and enlisting increase awareness. committed staff and senior executive support for cultural transformation. As a result of the sustained ■ Hand hygiene compliance was observed. Staff and significant reduction in MRSA-related infections, monitored usage patterns of alcohol hand sanitizer the MRSA Prevention Initiative expanded to include The Toyota Production System Approach The Toyota Production System (TPS) approach is a assessment of the current state of affairs and a plan systems engineering strategy used in manufactur- for improvement that is, in effect, an experimen- ing. The central principle is that all work processes tal test of the proposed changes. Managers who are controlled experiments continuously being employ TPS do not tell workers and supervisors improved by the people doing the work. TPS relies specifically how to do their work. Rather, they use on the workers controlling the change, thereby a teaching and learning approach that allows their allowing more work efficiency and success. The workers to discover the rules as a consequence of TPS model holds that people are the most signifi- solving problems. Identifying problems is just the cant corporate asset and that investments in their first step. In order for people to consistently make knowledge and skills are necessary to build com- effective changes, they must know how to change petitiveness. Managers are expected to be able to and who is responsible for making the changes. perform the jobs of everyone they supervise and TPS explicitly teaches people how to improve and also to teach their workers how to solve problems does not expect them to learn strictly from personal according to the scientific method. The leader- experience. TPS creates ownership by holding staff ship model applies as much to first-level team accountable.1 leader supervisors as it does to those at the top of the organization. This evolves into a cascading The Four Rules of TPS pathway for teaching, which starts with managers 1. All work shall be highly specified as to the con- delivering training to each employee. tent, sequence, timing, and outcome. The main objectives of the TPS approach are to 2. Every “customer supplier” connection must design out excess work and inconsistency and be direct, and there must be an unambiguous to eliminate waste. The challenge with TPS is to yes-or-no way to send requests and receive facilitate a culture change so that staff adopts the responses. TPS approach and related interventions as a com- ponent of the traditional work process. A cultural 3. The pathway for every product and service must transformation allows an organization to reach its be simple and direct. goals, anchor the changes in practice, and sus- 4. Any improvement must be made in accordance tain ongoing compliance. Since TPS relies on the with the scientific method, under the guidance workers controlling the change, staff are engaged, of a teacher, at the lowest possible level in the empowered, and provided resources to be suc- organization. cessful. Shared decision making improves staff satisfaction. Note 1. Spear SJ, Bowen HK. Decoding the DNA of the The principles of TPS include using a rigorous Toyota Production System. Harv Bus Rev 1999 Sep- problem-solving process that requires a detailed Oct;77(5):97-106. Page 28 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 1—March 2009 Pennsylvania Patient Safety Advisory other VAPHS units, and ultimately, a national general surgical unit had the highest rating for shared Veterans Health Administration (VHA) directive decision making. was instituted. In 2005, the initiative expanded to all units within Rationale/Motivation for Instituting the Initiative the acute care and long-term care facilities. VAPHS developed a living document, outlining the plan VAPHS employed TPS in order to make the neces- of action and conducted focus groups with staff sary system changes, which enabled the healthcare members to assess existing knowledge and atti- worker to implement active surveillance and appro- tudes regarding MRSA. Allowing for ongoing priate precautions. The challenge was to facilitate a evaluation and change helped sustain the cultural culture change so that nursing staff employed TPS transformation. and related interventions as a component of the traditional nursing process. This cultural transforma- In addition to TPS, VAPHS adopted the use of tion was regarded as necessary to achieve the goal, as positive deviance (PD), an approach to behavioral well as to anchor the changes in practice and sustain and social change that has proven effective in solv- ongoing compliance. Since TPS relies on the workers ing health-related problems in countries outside the controlling the change, nursing staff were immedi- United States.9,10 (For more information, see “The ately engaged, empowered, and provided with the Positive Deviance Approach.”) resources to be successful. One aspect of TPS was to Evidence of Nursing Leadership change work to be more efficient. Staff satisfaction A nurse coordinator was selected to lead the “Get- increased in the area of shared decision making. ting to Zero” initiative, educate staff, and implement Specifically, in comparison to all VAPHS acute inpa- changes. Nursing leadership supported the dedicated tient units, the nurses working on the piloted 36-bed nurse coordinator and the changes recommended by The Positive Deviance Approach Positive deviance (PD) is a development approach capacity of people to discover and implement based on the premise that solutions to community home-grown solutions to long-standing problems.3 problems already exist within the community. PD differs from traditional needs-based or problem- The PD approach has six steps: solving approaches in that it does not focus Define. The group begins its work by defining the primarily on identification of needs and the exter- problem and describing what success would look nal inputs necessary to meet those needs or solve like—the inverse of the problem statement. problems. Instead, it seeks to identify and optimize existing resources and solutions within the commu- Determine. The group determines whether there nity to solve community problems.1 are individuals who have already achieved success (i.e., positive deviants). Traditional models for change within an organiza- tion frequently do not work. Permanent solutions Discover. The group discovers the uncommon but can be achieved from within and not brought in demonstrably successful behaviors and practices from the outside. If an external agent brings new used by the positive deviants to solve the problem. resources and ideas into an organization to fix a problem, once the external agent leaves, the Design. The group designs an intervention, which problem may return because the recipients did enables its members to practice those demonstra- not assume ownership of the solution. Handing bly successful practices. problems to a group and allowing them to discover Discern. The group discerns the effectiveness of the things for themselves can attain far greater results intervention, which is determined by ongoing moni- than bringing the solution to the group and expect- toring and evaluation. ing behavioral change. The late Jerry Sternin, the “father of PD,” described positive deviants as Disseminate. The group makes the intervention “people whose behavior and practices produce accessible to a broader constituency. solutions to problems that others in the group who Notes have access to exactly the same resources have not been able to solve.“2 1. The Positive Deviance Initiative [Web site]. [cited 2009 Feb 23]. Boston (MA): Positive Deviance The Plexus Institute, a nonprofit organization that Initiative. Available from Internet: http://www. helps people use PD, bases its definition on the positivedeviance.org. observation that in most communities there are cer- 2. Sparks D. From hunger aid to school reform: positive tain individuals or groups (positive deviants) whose deviance approach seeks solutions that already exist. special practices/strategies enable them to find J Staff Develop 2004 Winter;25(1):46-51. better solutions to prevalent, seemingly intractable 3. Positive deviance (PD) and MRSA [Web site]. [cited problems than their peers who have access to the 2009 Feb 23]. Bordentown (NJ): Plexus Institute. same resources. PD projects can sustain themselves Available from Internet: http://www.plexusinstitute. because they are founded on the already-present org/complexity/index.cfm?id=3. Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 29 Pennsylvania Patient Safety Advisory staff. The coordinator engaged all interdisciplinary from March 2007 reflected a significant improvement team members associated with patient care on the in hand hygiene compliance rates for both acute and unit, including environmental services, management, long-term care. This data includes a 63% compliance physical therapy, and laboratory personnel. Through rate with entry hand hygiene and 88% with exit hand the engagement of surgical staff, collaborative rounds hygiene in comparison to March 2006, whereby the were established, which helped achieve a decreased entry hand hygiene compliance rate was reflected as length of stay from 6 to 4.5 days. Management sup- 48% and exit hand hygiene at 76%. With the height- ported by providing resources and/or removing ened awareness of MRSA and infection precautions, barriers (modified hospital systems) when needed. the use of PPE also increased. During expansion of the initiative to all acute and Nursing-Sensitive Quality Indicators. The outcome long-term care units, VAPHS dedicated a new, full- measures were MRSA HAIs and MRSA transmis- time MRSA prevention coordinator position to sions. From 2004 to 2008, the infection rate in acute long-term care. care decreased from 0.94 per 1,000 bed-days of care In transitioning to PD, focus group discussions (BDOC) to 0.25 per 1,000 BDOC (see Figure 1). inspired a core group of interdisciplinary volunteers Long-term care rates decreased from 0.54 per 1,000 to solve problems. Select long-term care residents BDOC in 2005 to 0.33 per 1,000 BDOC in 2006 assisted with changing the behavior of fellow veter- (See Figure 2). ans (e.g., performing hand hygiene). Referencing Figure 1. VAPHS Acute Care Campus MRSA guidelines from Partners in Care,11 staff and residents Healthcare-Associated Infections, 2004 through discussed how imperative hand hygiene is to prevent- 2008 Fiscal Years ing infections and created a hand hygiene educational pamphlet for fellow veterans. This approach, coupled NUMBER OF 1 0.94 with the Joint Commission National Patient Safety MRSA HAIS Goal 7 (compliance with World Health Organiza- PER 1,000 0.8 tion and/or CDC hand-hygiene guidelines),12 made BED DAYS OF CARE VAPHS successful in achieving its goals for “Getting to Zero.” 0.6 0.56 Scope of Initiative 0.44 0.44 VAPHS adapted TPS as a strategy to reduce the 0.4 transmission of MRSA infection on a 36-bed general 0.25 surgical unit over a four-year period, expanding to 0.2 an 11-bed surgical intensive care unit for the last 18 months of the initiative. Implementation was accomplished by changing workflow patterns, iden- 0 2004 2005 2006 2007 2008 tifying and eliminating impediments to compliance with established infection prevention and isolation FISCAL YEAR procedures. Regular reporting of MRSA HAIs and Reprinted with permission from VA Pittsburgh Healthcare System, transmission rates to staff and hospital management Pennsylvania. was a key component of change. These changes were Figure 2. VAPHS Long-Term Care Campus MRSA sustained over time to improve compliance with isola- Healthcare-Associated Infections, 2004 through tion procedures and reduce MRSA infection rates. 2006 Fiscal Years This initiative has been sustained throughout the organization for approximately six years—as evidenced NUMBER OF 1 by a reduction in MRSA HAI, a sustained increase in MRSA HAIS the use of personal protective equipment (PPE), and PER 1,000 0.8 improved hand hygiene compliance rates. BED DAYS OF CARE The VAPHS results serve as a model for MRSA reduc- 0.6 tion efforts regionally, nationally, and internationally. 0.54 Of particular note are the collective campaigning efforts with the U.S. Department of Veterans Affairs, 0.4 which resulted in a rollout of the initiative to all 165 0.3 0.33 VHA facilities in the United States in March 2007. 0.2 Impact Process Improvement. The key process monitors were 0 hand hygiene and contact precaution compliance. 2004 2005 2006 Staff ownership of the process drove both the clinical and systems improvement of this initiative. Active sur- FISCAL YEAR veillance culture compliance rose significantly in both Reprinted with permission from VA Pittsburgh Healthcare System, acute and long-term care settings. Observation data Pennsylvania. Page 30 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 1—March 2009 Pennsylvania Patient Safety Advisory A systemwide impact has been sustained to date safety. The medical center held regular and spontane- because of the quality of care delivery and healthcare ous meetings, employing the “discovery and action cost avoidance. Examples of tangible costs include dialogues” approach. The Plexus Institute provided the following: PD consultants to the medical center. ■ Twenty-two MRSA cases at $34,369 per case = Results one year later revealed that PD is “about peo- $756,118. ple in the community identifying the problems you ■ Cost of MRSA screening 2,536 total cases at can’t see from the outside, and coming up with novel $21.84 for 2 lab cultures = $110,772. ideas that work for them, right there,” according to a key player in the SMASH initiative. “It’s about ■ Opportunity savings valued at community ownership because [when] solutions are $756,118 - $110,772 = $645,346. community-driven, they are likely to be accepted. People don’t reject their own solutions.” Albert Einstein Healthcare Network During 2006, a rate of 0.535 infections per 1,000 Albert Einstein Healthcare Network (AEHN) is a patient-days was reported. Sixty-five cases of alcohol- 1,200-bed integrated delivery network serving the based gel and 33,000 gowns were used per quarter. communities of North Philadelphia and Montgomery County, Pennsylvania. The network provides health- By 2007, the number of MRSA-related HAIs had care services through the Albert Einstein Medical decreased to 0.408 infections per 1,000 patient- Center and Einstein at Elkins Park hospitals, Moss- days. In the first quarter of fiscal year 2008, the Rehab and Belmont Behavioral Health divisions, rate decreased by 27%, or 0.39 infections per 1,000 Germantown Community Health Services, Willow patient-days (2008 data not reflected in Figure 3). Terrace (a nursing home), Willowcrest (a center for Alcohol-based gel use had increased to 125 cases, subacute care), outpatient facilities such as Center and 80,000 gowns were used per quarter. Based on One and Einstein Neighborhood Healthcare, and the decreasing HAI rates and increasing compliance a network of primary care and specialist practices with hand hygiene and isolation precautions, the PD throughout the community. approach was expanded to all the units. During 2006, 107 patients developed MRSA-related Summary of VAPHS and Einstein Programs HAIs at the medical center. These patients had an The nurse-led interdisciplinary projects at both the 8.3% higher mortality, an increase in average length VAPHS and AEHN programs demonstrate that initia- of stay of 19.75 days, and an increase in average vari- tives to control healthcare-associated MRSA can lead able costs of $33,347 compared to matched patients to a significant, sustained reduction in MRSA infec- who had not acquired a MRSA-related HAI. The per- tion in medical facilities in which MRSA had become centage of clinical isolates of MRSA steadily increased highly endemic. Lessons learned include the ability to over the years and was approaching 70% in 2006. introduce a change in culture by empowering staff to No surveillance cultures were being performed for take ownership of the initiative. By taking ownership, MRSA, and hand hygiene compliance was variable, staff developed the ability to change the behavior averaging 40% to 60%. PPE was often unavailable upon entry to isolation rooms. Figure 3. AEHN MRSA Healthcare-Associated Infections, 2006 through 2007 In May 2006, driven by concern for the increasing incidence of MRSA together with unacceptable NUMBER OF compliance rates of hand hygiene, the medical cen- MRSA HAIS ter took steps to develop and implement a MRSA 59 60 reduction program known as SMASH (Stop MRSA Acquisition and Spread in our Hospital) by using 50 the PD approach. PD encourages the kinds of cul- 46 43 43 tural changes that help people consistently adhere 40 to practices known to control infections. The staff at Einstein rapidly took ownership of developing the 30 initiative. Pilot projects began on the brain injury unit at MossRehab, a surgical intensive care unit, a 20-bed 20 oncology and transplant unit, and a “step-down” unit. Multidisciplinary teams of hospital staff began to 10 examine their own roles in preventing infections. Risk reduction strategies similar to those of the 0 January–June July–December January–June July–December VAPHS program were instituted, using evidence- 2006 2006 2007 2007 based guidelines for preventing transmission and acquisition of MRSA. Of note at the medical center SIX-MONTH INTERVALS were the dedication and devotion of staff members Reprinted with permission from Albert Einstein Healthcare Network, to sustaining the program for the benefit of patient Pennsylvania. Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 31 Pennsylvania Patient Safety Advisory around infection control practices. Staff ownership Saf Advis [online]. 2007 Dec [cited 2009 Feb 23]. Avail- has far more of an impact than the traditional educa- able from Internet: http://patientsafetyauthority.org/ tional programs alone. The TPS approach empowered ADVISORIES/AdvisoryLibrary/2007/dec4(4)/ VAPHS staff to change systems and processes. Pages/124.aspx. Through the PD approach, both VAPHS and AEHN 6. Verhoef J, Beaujean D, Blok H, et al. A Dutch approach created and implemented staff-owned and -operated to Methicillin-resistant Staphylococcus aureus. Eur J Clin MRSA prevention programs that are efficient, measur- Microbiol Infect Dis 1999 Jul;18(7):461-6. able, and sustainable. In addition, the success at both VAPHS and AEHN is also credited to support from 7. Spear SJ, Bowen HK. Decoding the DNA of the the health system administration teams, who diligently Toyota Production System. Harv Bus Rev 1999 Sep-Oct 1999;77(5):97-106. supported the housewide initiatives and took great pride in attaining their HAI reduction goals. 8. Shlaes DM, Gerding DN, John JF Jr, et al. Society for Notes Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the 1. Healthcare Infection Control Practices Advisory Com- Prevention of Antimicrobial Resistance: guidelines for mittee. Management of multidrug-resistant organisms the prevention of antimicrobial resistance in hospitals. in healthcare settings [online]. 2006 [cited 2009 Jan 29]. Clin Infect Dis 1997 Sep;25(3):584–99. Available from Internet: http://www.cdc.gov/ncidod/ dhqp/pdf/ar/mdroGuideline2006.pdf. 9. Lapping K, Marsh DR, Rosenbaum J, et al. The positive deviance approach: challenges and opportunities for the 2. Davis KA, Stewart JJ, Crouch HK, et al. Methicillin-resis- future. Food Nutr Bull 2002 Dec;23(4 Suppl):130-7. tant Staphylococcus aureus (MRSA) nares colonization at hospital admission and its effect on subsequent MRSA 10. Positive deviance (PD) and MRSA [Web site]. [cited infection. Clin Infect Dis 2004 Sep 15;39(6):776-82. 2009 Feb 23]. Bordentown (NJ): Plexus Institute. Avail- 3. Jarvis WR, Schlosser J, Chinn RY, et al. National preva- able from Internet: http://www.plexusinstitute.org/ lence of methicillin-resistant Staphylococcus aureus in complexity/index.cfm?id=3. inpatients at US health care facilities, 2006. Am J Infect 11. Steris Corp. All hands clean: a hand hygiene compliance Control 2007 Dec;35(10):631-7. solution from Steris [online]. 2006 [cited 2009 Feb 23]. 4. MRSA in Pennsylvania hospitals. PHC4 Research Available from Internet: http://www.steris.com/aic/ Brief [online]. 2006 Aug [cited 2009 Feb 23]. Available Hands_Clean_files/Handwashing%20brochure.pdf. from Internet: http://www.phc4.org/reports/research- 12. Joint Commission. 2009 National Patient Safety Goals briefs/082506/docs/researchbrief2006report_mrsa.pdf. [online]. 2009 [cited 2009 Mar 3]. Available from Inter- 5. Prompt identification and effective communication of net: http://www.jointcommission.org/patientsafety/ status may reduce MRSA infections. PA PSRS Patient nationalpatientsafetygoals. Page 32 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 1—March 2009 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 6, No. 1—March 2009. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2009 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS 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 An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. 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 nearly 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. 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.