SAVES, SYSTEM IMPROVEMENTS, AND SAFETY-II “Saves, System Improvements, and Safety-II” is an occasional AEDs may be needed in emergencies when seconds count and feature of the Pennsylvania Patient Safety Advisory, highlighting delays in treatment can contribute to poor neurologic outcomes successes of healthcare workers in keeping patients safe. The or even death. Imagine discovering an equipment mismatch in Safety-II approach assumes that everyday performance variability the middle of a resuscitation and having to scramble to find the provides adaptations needed to respond to varying condi- right parts. Even though this healthcare worker was complet- tions and that humans are a resource for system flexibility and ing a routine—perhaps even a mundane—task, he or she went resilience. beyond just “checking the box” that all of the necessary parts were available and made sure that all of the parts fit together Exceeding ”Routine” Checks of AEDs correctly. This person even went a step further, recognized that A healthcare worker completing routine checks on an AED this mismatch could affect more than one AED, and checked on (automated external defibrillator) noted that the defibrillation the other similar devices throughout the facility. These actions electrodes (pads) in the emergency cart were not compat- helped to ensure that if an AED were needed for an emergency anywhere in the facility, it would be fully functional. ible with the AED. Further investigation revealed that multiple AEDs throughout the facility were affected. The correct pads were ordered and installed. Vol. 13, No. 4—December 2016 Pennsylvania Patient Safety Advisory Page 171 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 4—December 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 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 http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website 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 website at http://www.patientsafetyauthority.org. An Independent Agency of the Commonwealth of Pennsylvania 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 50 years, ECRI Institute marries experience and indepen- dence 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. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.