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Pressure Ulcer1290834149/1/2015 6:00:00 AMPressure UlcerManitoba HealthThis alert addresses the patient safety incidents of development of pressure ulcers by clients after admission to a health care facility. A review of multiple incidents found that the limitations of the Braden Scale and the lack of guidance to direct staff to the appropriate interventions increased the likelihood the pressure ulcer would progress to stage 3 or 4. A recommendation to mitigate recurrence of similar incidents is provided.5/31/2017 7:22:37 PM3
Pressure Ulcer1291134119/1/2015 6:00:00 AMPressure UlcerManitoba HealthThis alert addresses the development of pressure ulcers in a number of clients admitted to health care facilities. In reviewing the incidents, the following contributing factors were found: • The lack of documentation and gaps in the implementation of interventions to reduce pressure may have increased the likelihood that the pressure ulcers would progress to stage 3 or 4. • Lack of consistency regarding pressure reduction mattress availability increased the likelihood that the most appropriate mattress may not be implemented in a timely manner and possibly contributed to the development of the pressure ulcers. • Inconsistent interdisciplinary care plan and inconsistent communication in some of the cases regarding wound care along with the lack of discussion with the patient/family as to the agreed upon goals regarding wound care increased the likelihood that the pressure ulcers would progress to stage 3 or 4. Several recommendations for improvement are provided to mitigate the likelihood of recurrence of these types of incidents.5/31/2017 7:22:41 PM3
Fall from Bed with Serious Injury1292034024/1/2015 6:00:00 AMFallsManitoba HealthThis alert describes a patient safety incident of a fall after side rails of the bed were removed without implementing alternative falls prevention strategies. The incident is described. A personal care home resident fell from their bed following the removal of side rails when they were considered to be a risk for entrapment in the gap between the rails. The fall resulted in a head injury and a fractured radius. Factors contributing to the incident were as follows: • The resident’s bed side rails had been removed due to bed design safety concerns. When the side rails were removed, alternative falls prevention interventions were not implemented. It was recognized that a high/low bed was required for this resident. • The safety concerns emphasized the dangers related to side rail use requiring the removal of bed side rails. Once completed, fall prevention interventions and strategies were not the primary focus. • Changes in the workforce contributed to a lack of continuity of care and lack of communication to direct care staff. • The presence of multiple competing priorities contributed to the deficiency in communication related to assessing risk and development of falls prevention strategies following the removal of the bed rails. Recommendations to mitigate the likelihood of recurrence of this type of incident are provided. 5/31/2017 7:22:52 PM4
Incident Reported with Cold and Flu Product12923339911/4/2015 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis newsletter discusses the patient safety incidents that can occur with non-prescription medications that are available as combination packs. These products contain more than one ingredient, and some products even contain more than one type of tablet within the same package. For example, some cold and flu products contain different tablets for daytime and nighttime use. Each type of tablet contains ingredients that will help relieve cold and flu symptoms, but the ingredients in the nighttime medicine can help with sleep, while the ingredients in the daytime medicine do not cause drowsiness. Mixing up the two products could cause problems; for example if the nighttime product was taken during the day it could cause drowsiness and impair the ability to drive. A specific incident is described where a consumer purchased a cold and flu product that was sold as a combination package, with separate blister packs of medicine intended for daytime or nighttime use. One blister pack contained green tablets (intended for daytime) and the other blister pack contained white tablets (intended for nighttime). At bedtime, the consumer took what was believed to be the nighttime tablet to help with sleep, but had difficulty sleeping. This affected the consumer’s work productivity the following day. The consumer realized later that the tablet taken the previous evening had been one of the daytime tablets. The consumer also assumed that the green pills were for nighttime use and the bright white ones were for daytime. Suggestions are provided for consumers to help prevent patient safety incidents with combination packaged medications. As well recommendations for practitioners to assist consumers in avoiding medication mix-ups are provided. 5/31/2017 7:22:56 PM6
Application of TALLman Lettering for Selected High-Alert Drugs in Canada12931339210/30/2015 6:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis Safety Bulletin describes the development and application of TALLman lettering as a strategy to reduce medication errors. TALLman lettering is a method of applying uppercase lettering to sections of look-alike, sound-alike (LASA) drug names to bring attention to their points of dissimilarity. By accentuating the points of difference, the application of TALLman lettering to a drug name may alert healthcare providers that the drug name in question can be confused with another drug name. However, overuse of the technique may reduce its effectiveness, as names may cease to appear novel. Therefore, the use of TALLman lettering should be limited to drug name pairs associated with significant risk to patient safety. TALLman lettering will have the greatest impact on the differentiation of LASA drug names if the approach to capitalization is applied consistently. Key milestone projects of the Institute of Safe Medication Practices (ISMP) Canada and other collaborative partners are described. The bulletin contains a list of TALLman lettering for look-alike, sound-alike drug names in Canada as well as the source for this list. 5/31/2017 7:28:14 PM9
Abbreviations: A Shortcut to Medication Errors13057PA0153/1/2005 7:00:00 AMMedicationPennsylvania Patient Safety Authority (USA)This Patient Safety Advisory discusses medication patient safety incidents that occur as a result of using confusing abbreviations and non-standard dose designations. A number of patient incidents are described and recommendations to mitigate risk provided.7/7/2015 9:22:37 AM6
Packaging and Labelling Are at Root of Many Medication Errors13193CPSO018/1/2010 6:00:00 AMMedicationCalifornia Hospital Patient Safety Organization (USA)"This article addresses how medication packaging and labelling can contribute to medication patient safety incidents. Several examples of packaging and labelling problems are given with diagrams to illustrate the narrative. Actions to reduce risk, based on the UK National Health Service (NHS) guide for labelling and packaging of injectable medications, are provided. "7/7/2015 9:20:31 AM3
Safer ambulatory syringe drivers13196NPSA03112/16/2010 7:00:00 AMDeviceNational Health Service Commissioning Board (England and Wales)This Rapid Response Report discusses potential and actual patient safety incidents that have resulted from over or under infusion of opioids and other palliative care medications, resulting in harm to patients. Use of syringe drivers which have rate settings in millimetres (mm) of syringe plunger travel versus rate settings in millilitres (mL) of fluid to be infused have resulted in errors providing the wrong rate of infusion caused by inaccurate measurement of fluid length or miscalculation or incorrect rate setting of the device. Dose errors also occur because of different models using mm per hour or mm per 24 hours. Other issues include syringes becoming dislodged, inadequate device alarms and lack of internal memory (a technical issue which makes establishing the reason for any over or under-infusion difficult).7/7/2015 9:06:58 AM7
Extravasation of neonates revisited13199NPSA0452/26/2010 7:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This signal provides good practice and guidance from local trusts to reduce risks of extravasation injury to neonates from intravenous fluid. 7/7/2015 9:21:38 AM3
Overdose of intravenous paracetamol in infants and children13200NPSA04710/29/2010 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This signal address the risk of harm to infants and children from inadvertent overdose of intravenous paracetamol / acetaminophen and provides some actions to reduce risk. One patient safety incident is described whereby the healthcare provider intended to give a dose of paracetamol 10 mg/kg intravenously (IV) but gave 100 mg/kg instead. A doctor was summoned immediately and the overdose was treated. Treatment consisted of HDU (high dependency unit) level monitoring, acetylcysteine (Parvolex®) infusion and monitoring of blood tests. Contributing factors to paracetamol overdoses include: - lack of awareness amongst healthcare professionals of neonatal and paediatric drug dosage regimens; - patients receiving doses of paracetamol in both theatre and ward due to poor documentation; - human error relating to setting up infusion pumps to administer intravenous paracetamol (incorrect rate or incorrect/ no volume to be infused (VTBI)); - confusion between dosing regimens for oral and intravenous paracetamol with clinical staff believing they are interchangeable; - 10 times dose calculation errors in both the prescription and administration of intravenous paracetamol. Brief actions to reduce risk are provided and further guidance can be found on the MHRA Website. 7/7/2015 9:22:43 AM3