Becker's Clinical Quality & Infection Control

13 PATIENT SAFETY & OUTCOMES Penn Medicine hospital cited over wrong-site surgery By Mackenzie Bean P ennsylvania health officials have cited Lancaster (Pa.) General Hospital for several safety issues in recent months, including a wrong-site surgery, Penn Live reported Feb. 23. e Pennsylvania Department of Health initiated "special monitoring" investigations into the hospital, part of Philadelphia-based Penn Medicine, aer an anonymous complaint. is type of probe occurs when the department suspects ongoing issues at an organization, a spokesperson told Penn Live. State reports cited by the publication show a surgical team at the hospital performed reconstruction surgery on a patient's wrong ankle in December. A staff member marked the correct ankle prior to surgery, but did not place the mark within two inches of the surgical site, as per hospital policy. Another employee placed a tourniquet on the wrong leg, and the surgical team realized the error shortly aer the operation. Two months prior to this incident, the hospital was also cited for failing to fill a diabetes patient's insulin pump and for not reporting the death of a woman who died from bleeding complications several weeks aer a cesarean section. e state fined the hospital $40,000 for these reporting failures and ordered Lancaster General to create correction plans for all other citations. "Ensuring the safety of all patients is our top priority. We take any regulatory or inspection findings very seriously and are cooperating fully with the PA Department of Health on these matters," a spokesperson for Lancaster General Hospital told Becker's. n Paxlovid rebound rate is 14%, study finds By Paige Twenter T he risk of a Paxlovid rebound may be higher than previously reported, according to a study published Feb. 22 in Clinical Infectious Diseases, an Oxford University Press journal. Pfizer researchers have previously said rebound happened among 2.3 percent of Paxlovid users and 1.7 percent of the control group, but others have been wary about this figure. The recent analysis included 170 patients who either received a placebo or nirmatrelvir and ritonavir — the two generics packaged as Pfizer's antiviral COVID-19 drug. For those who took Paxlovid, more than 10 percent had a rebound, which the study defined as when a person tests negative for COVID-19 after treatment and then experiences a "temporary return of symptoms with or without a positive test." Of the COVID-19 patients who took Paxlovid, 14.2 percent tested positive again days after testing negative, and 18.9 percent had a symptom rebound. This is the "best data so far on rate of symptomatic rebound after Paxlovid, despite limitations," Walid Gellad, MD, director of the University of Pittsburgh's Center for Pharmaceutical Policy and Prescribing, said on Twitter. "Not rare. Not 5 percent." The study was conducted between August and November. Three out of the 43 people in the control group, or 7 percent, also reported a symptom rebound, while 9.3 percent had a viral rebound. For the study's next phase, the researchers will test for "any virus specific or host specific factors" into the rebound phenomenon. n New York hospital fires nurse who roughly handled newborn By Erica Carbajal G ood Samaritan University Hospital in West Islip, N.Y., has fired a nurse who appears to have roughly handled a newborn baby on a video filmed by the child's father, according to a report from News12 New Jersey. The child's family members said the incident occurred Feb. 6. Video obtained by the news outlet appears to show an individual in the hospital's neonatal intensive care unit pick up the infant, flip them over and roughly put them back down in the bassinet. The video appears to be filmed through a small opening in a closed curtain outside of the neonatal ICU. The child's father immediately alerted hospital staff and the nurse was sent home, family members told News12. Rockville Centre, N.Y.-based Catholic Health, which owns Good Samaritan University Hospital, said the individual has been terminated. "Upon learning of this incident, swift and immediate action was taken, including conducting an investigation and consequently terminating the individual involved," the system said in a statement emailed to Becker's Feb. 24. "Additionally, we reported the individual to the Department of Health for further review. Keeping our patients safe remains our paramount concern." Catholic Health also said it is "standard procedure" to have curtains in the neonatal ICU, citing the privacy of patients and families. "Immediate family members are permitted inside the nonatal ICU to spend time with their loved ones," the system said in their statement. The baby is doing well, the family told the news outlet. n

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