Safety message: Gait belts

Gait belts are used to help prevent patient falls. Therapy staff recently discovered a safety issue with the belts. The gait belt buckle with the prongs can slip off and if not reattached correctly, cause the belt to malfunction.   

The belt must be threaded through the buckle correctly so the ridges, or “belt grippers,” are in contact with the belt when tightened. 

The image below shows how the belt should be looped back onto the buckle properly. 

If the buckle is on the belt incorrectly, the buckle will seem to latch but it’s not actually locked in place, causing the buckle to pop open or slide off the belt when pulled.

Recommendations

• Prior to using the gait belt, check the buckle to ensure it’s on the belt correctly.
• The buckle is on the belt correctly when the solid side of the prongs faces out. If you can see the hollow side, the buckle is not on the belt correctly.

Great Catches

• Thank you, Angela Yocum from Soin Medical Center, for your Great Catch. Angela’s attention to detail and questioning attitude prevented a medication error. Angela received a bag of vasopressin that was incorrectly labeled as sodium bicarbonate. Angela’s patient was on sodium bicarbonate and the bag had her patient’s information. Angela could have easily hung it without another thought; however, Angela noticed the bag was small and needed to be mixed with D5W one liter. This was her first clue that something wasn’t right. After investigating further, she discovered the bag of vasopressin incorrectly labeled as sodium bicarbonate was supposed to go to another patient in the ICU. Thank you, Angela.

• Thank you, Erin Albrethsen, Jennifer Lawson, and Abigail Mayhugh from the Kettering Health Cancer Center Infusion Center, for your Great Catch. These three employees were part of the team to discover that a patient was incorrectly registered under another patient’s name. Their diligence prevented the patient from incorrectly receiving a dose of chemo.

Medication safety: Oral versus IV syringes

Incorrect route of medication administration is among the highest risk types for medication errors. Certain medications are formulated to be processed differently by the body and may contain substances that can prove life-threatening, if not first processed by the body’s normal mechanisms of absorption.

Various organizations including the Institute for Safe Medication Practices (ISMP), have published recommendations to help prevent the inadvertent injection of non-IV liquids. Universally these recommendations include the use of specially designed syringes that do NOT attach to the standard luer lock mechanism found on IV syringes. At Kettering Health, we utilize oral syringes with a “slip tip” style of fitting that will not screw onto an IV port.

In the pictures below, you can see the difference between the typical IV tip with a luer lock and that of an oral syringe. Normal workflow should NEVER require the transferring of contents from one syringe to the other.