Becker's Clinical Quality & Infection Control

16 PATIENT SAFETY & OUTCOMES Hand-bell system leads to patient death at New Mexico hospital By Erica Carbajal A system that required patients to use hand bells to call for help led to the death of a patient at Gallup, N.M.-based Rehoboth McKinley Christian Hospital in Januar y, Source New Mexico reported Aug. 30. The news outlet reviewed a July CMS inspection report that found the patient died after using a hand bell to call for help rather than a modern call-light system. The hospital switched to the hand-bell system in March 2021. Patients were previously able to call for help by pressing a button on their hospital beds. CMS' inspection report said the malfunctions meant "staff could not efficiently call a code" on a patient whose condition rapidly deteriorated, and the hand-bell issue resulted in three "adverse events" in Januar y, Source NM reported. Patients sur vived after being transferred to the intensive care unit in two instances, and in the third instance, the patient died after family requested staff cease life support. The inspection also found staff did not report the three adverse events to the hospital's quality and risk committee. An employee who listed the events as "no harm" done by a staff member has since been fired, according to the CMS report. Source NM said a spokesperson for the hospital had not responded to a request for comment Aug. 30. n Wireless sock monitoring system reduces patient falls, nurses find By Erica Carbajal A study led by nurses at the Ohio State University Wexner Medical Center involving 569 hospitalized patients found the use of a wireless sock monitoring system resulted in zero falls. Researchers evaluated the effectiveness of Palarum's Patient is Up Smart Socks. The wireless system involves socks with pressure sensors that detect when a patient is trying to stand up and badges worn by nurses. The system alerts the three nurses closest to the alarming room when an attempt to stand is detected. The study period covered 2,211.6 patient days at the medical center's neurological and neurosurgical units and no other fall prevention system was used, according to findings published Aug. 19 in the Journal of Nursing Care Quality. During the 13-month study period, there were 5,010 safety alarms from the system. Only 11 were reported to be false alarms, meaning 99.8 percent of the safety alerts were true patient stands, researchers said. No falls occurred during the study period and the median nurse response time was 24 seconds. "We observed zero falls, which was a lower fall rate among the patients wearing these socks than the historical fall rate of 4 falls per 1,000 patient-days," said Tammy Moore, PhD, RN, senior study author and associate chief nurse of Ohio State's Neurological Institute. n Pfizer's antiviral drug could result in 'Paxlovid mouth' By Paige Twenter P axlovid, Pfizer's popular antiviral drug treatment, is leaving a sour taste in people's mouths, The Wall Street Journal reported Aug. 16. One of the most common side effects of Paxlovid — which is administered at home for five days, twice a day — is a mild taste disorder. In clinical trials, about 6 percent of patients experienced dysgeusia, and less than 1 percent in the placebo group experienced it. Some have dubbed the side effect "Paxlovid mouth," a taste that one person described as "the smell that hot garbage has, but in your mouth," according to the Journal. Unless someone experiences an allergic reaction or vomiting, health experts advise people to stomach the bad taste and not to end the regimen early because of the risk of a COVID-19 rebound. "If you do not take the full course, you are adding an opportunity for the virus to hang around with less drug presence to block replication," Scott Roberts, MD, an infectious disease specialist at New Haven, Conn.-based Yale School of Medicine, told the Journal. The latest published data indicates between 1 and 2 percent of people have a rebound — when someone takes Paxlovid, tests negative, then tests positive again a few days later — but some virologists have said the course should be stretched past five days. n

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