QSA Good Catch PSN# 71980: “At first set of care, removed infants CPAP mask and noted deep red indentation at his bridge of nose. RT changed to CPAP prongs and 2 hrs later there was marked improvement... Less red and less indentation noted.”      I sent the following email to the staff member who submitted the PSN: “Rianne,     Thank you very much for submitting this PSN about the redness due to CPAP mask.  I know there is sometimes a feeling that PSNs go into a “black hole” and no one ever looks at them, but we really do take them very seriously.  The case you described was a good example of how when we see things are not right and act on them, we can positively impact the outcome for the patient.  Thank you very much for taking the extra step for patient safety and letting us know about this event. Thank you, Sara Odell

QSA Good Catch Big kudos to Jessica Leiss for reporting an issue that has led to some EPIC changes. A few weeks ago, a patient with dysphasia received a diabetic diet meal tray when an MD put in the diabetes order set (sliding scale, education, etc.). The patient was previously NPO status. When the diabetes order set is entered into EPIC, the diabetic diet defaults for the patient and previous diet orders are discontinued. Because of reporting on this issue, the diet on this order set has been changed to unspecified. Thanks Jessica for reporting!  Courtney West, RN, BSN, CCRN

QSA Good Catch An AOP Pre-Post RN had a patient receiving platelets preoperatively. A Physician’s assistant ordered Heparin given subcutaneously. The Pre-post RN was concerned that the low platelet count contraindicated the administration of the anticoagulant, Heparin, and contacted the attending. The attending cancelled the order. A big picture catch by a solid RN. Claudia Scroggs

QSA Good Catch MD accidently ordered heparin gtt 800 units/kg/hour instead of 800 units/hr. It appeared in EPIC that the pharmacy had approved the order (when the medication was scanned there was not a msg indicating otherwise)when the RN was programming the alaris pump there was not a soft or hard stop to alert the RN to the large dose. the RN caught the high ml/hr and the gtt was not ever started. This RN was given a prize at the SICU staff meeting.