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Prevention Strategy - Pressure ulcer associated with a device134371946/1/2011 6:00:00 AMPressure UlcerNew Jersey Department of Health and Senior Services (USA)This alert addresses the development of patient safety incidents of pressure ulcers related to the use of a respiratory device. Patients have developed Stage III and IV Pressure Ulcers associated with a device (such as BiPAP, tracheostomy). Contributing factors to the events were failure to perform a full body assessment, including areas of skin covered with a device. Strategies to prevent this type of patient safety incident are provided.7/7/2015 9:26:36 AM3
Deteriorating Patient Condition Associated with Medical Gas System Dysfunction 1294535303/1/2017 7:00:00 AMMedical GasManitoba HealthThis alert describes a fatal patient safety incident related to dysfunction of a medical gas (oxygen) system. The incident is described. An elderly patient with few medical conditions or health issues presented to an Emergency Department with a three day history of nausea, vomiting and upper abdominal pain. The patient did not have any signs or symptoms of an acute condition except for an elevated white blood count. Vital signs were recorded within normal limits for their age. The patient was admitted to hospital where he/she received therapy to correct dehydration. It was noted that the patient had previously indicated in an advance care plan the desire to not be resuscitated. Approximately 32 hours later, the patient began to exhibit behaviour that was described as “strange” by their family. On assessment, the patient’s oxygen levels were found to be low, the patient was short of breath and was confused about their whereabouts. Following the administration of high concentration oxygen, diagnostic tests showed right lower lobe pneumonia, possibly related to aspiration. Challenges were noted during attempts to provide high concentration oxygen with the medical gas equipment; there were difficulties with getting adequate pressure from the medical gas system despite attempts using a number of different oxygen regulators. During this time, the patient did not receive supplemental oxygen to treat his/her oxygen deficiency. Despite aggressive treatment, the patient’s condition continued to decline. The patient died approximately seven hours later. Contributing factors included the following: • The wall oxygen outlet near the bed was damaged. • The condition of the medical gas system located behind the wall may have been disturbed by the bed frame with a monkey bar apparatus attachment. • No standardized regional process for medical gas system functioning checks was in place. • The patient may not have been receiving adequate oxygen flow potentially further compromising his/her respiratory status. • Documentation regarding the clinical condition of the patient receiving oxygen therapy and their response to therapy was inconsistent. System learnings are provided in the alert.9/1/2017 8:54:09 PM11
Neonatal Death12946352910/1/2017 6:00:00 AMObstetrics/ Labour and DeliveryManitoba HealthThis alert describes a fatal patient safety incident of a neonatal death. The incident is described. A gravida 2 Para 1 (giving birth for the second time) patient was admitted to an acute care centre at 0448h. Due to fetal bradycardia (low heart rate) and breech presentation (buttocks first), the patient underwent an emergency Cesarean Section (C-section). Following the C-Section (birth time noted as 0841h), the neonate had depressed apgar scores. The neonate was transferred to a tertiary care facility and passed away. Contributing factors to the incident included the following: - differing definitions of the urgency of the C-section - lack of expressive/receptive communication regarding the urgency of the event - lack of fetal heart rate monitoring during OR prep and during transfer to the OR. System learnings are provided in the alert9/1/2017 8:54:10 PM22
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
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
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