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Burns Due to Incorrect Handling of an Electrosurgical Pencil12510312010/1/2011 6:00:00 AMSurgeryJapan Council for Quality Health CareThis alert discusses patient safety incidents of burns due to an electrosurgical pencil not being properly stored in its holder. A specific incident is described. The physician was holding an electrosurgical pencil (although not in use) with one hand, and pointed the tip towards the patient. The switch of the electrosurgical pencil was inadvertently pushed, and the pencil was activated during incision of the fascia for an operation intraperitoneal cavity. Skin on the right side of the abdomen was damaged. Recommendations to prevent similar incidents are provided.7/22/2015 5:51:38 PM3
Ensuring patients are not discharged from the Emergency Department without review of test results or plan for follow-up on pending results1290834637/1/2015 6:00:00 AMCare ManagementMinnesota Hospital Association (USA)This alert discusses patient safety incidents that occurred in the Emergency Department and were related to diagnostic tests . The Minnesota adverse health event reporting revealed a pattern of events occurring in the Emergency Department (ED) in which a patient death or serious injury occurred due to: 1) patients being discharged from the ED without review and appropriate action taken on available critical test results; or 2) patients being discharged from the ED with pending results, such as urine culture results, without timely follow-up action based on the results. The contributing factors to these events included the following: • Lack of a forcing function to prevent patient discharge from the ED when test results that are expected to be available during the ED visit have not been reviewed and action taken. • Lack of a process to follow-up on pending results, including urine cultures, following patient discharge from the ED due to: • Urine cultures sent to provider inbox (due to not being included as a critical test result) and initially overlooked. • No redundancies or escalation process in place if provider does not review and/or act on result. • Lack of a defined process to determine the provider (i.e., ED provider, hospital service, primary care provider) responsible for follow-up on pending results. Recommendations to prevent similar incidents are provided.12/19/2016 11:26:49 PM3
Cerebrospinal Fluid (CSF) Sample Transport1287433787/13/2015 6:00:00 AMSpecimen/LaboratoryAlberta Health ServicesThis alert discusses the need to provide expedited transport and processing of a critical laboratory specimen to ensure an optimal patient outcome. The specimen discussed is a cerebrospinal fluid (CSF) sample. CSF is obtained from a lumbar puncture from a patient suspected of meningitis. Meningitis is a disease associated with a high morbidity and mortality. Rapid initiation of appropriate antimicrobial therapy is essential to improved clinical outcome. The factors that contribute to sub-optimal processing of the CSF sample include the following: - Transport of CSF samples from collection to receipt in the laboratory does not meet the turnaround time required to provide optimal results for patient care. - CSF samples must be sent to the laboratory immediately (within 15 minutes) after collection to ensure sample integrity and not delay efficient laboratory processing and rapid reporting of initial results (i.e. gram stain). Recommendations are provided to reduce the risk of sub-optimal processing of the CSF sample and a negative impact on patient care.3/17/2016 4:51:30 PM20
Check Labels Carefully When Selecting Gravol Products!12331365/4/2012 6:00:00 AMMedicationSafeMedicationUse.caThis alert advises consumers about potential patient safety incidents with products that have similar brand names but contain different ingredients. Previously there was confusion between the original Gravol product and a Gravol Natural Source product that contains ginger. Now, a new Gravol Natural Source product, called Gravol Multi-Symptom, is also available. The original Gravol product contains the medicine dimenhydrinate. Gravol Natural Source products do not contain any dimenhydrinate. Gravol Ginger lozenges and tablets contain ginger. Gravol Multi-Symptom contains ginger and willow bark. Willow bark contains a number of compounds, including salicin, one of a class of medicines known as "salicylates". Acetylsalicylic acid (also called ASA or Aspirin) is one well-known example of a salicylate. If consumers have been advised not to take ASA or other salicylates, they should not take Gravol Multi-Symptom. For example, this product should not be taken by anyone who is allergic to salicylates or by people who are taking certain blood thinners. Suggestions to consumers to avoid medication incidents with Gravol products are provided.10/21/2015 4:42:00 AM3
Alert: Take Care with Medicine Patches!12334387/4/2012 6:00:00 AMMedicationSafemedicationuse.caThis alert discusses patient safety incidents that can occur with the use of medication available as a patch. Patches provide a convenient way for medicine to be absorbed into the body. They act over extended periods of time (for example, for a day or a week) and each patch can contain a large amount of medicine. However, medicine patches, like other forms of medicine, can result in serious harm if not used as directed. Recently, the Institute for Safe Medication Practices in the United States shared the story of a 2-year-old boy who was found unconscious 2 days after visiting a relative in a nursing home. He later died, and a patch containing fentanyl, a very strong pain killer, was found in his throat. Advice for consumers to help avoid medication incidents for those who use medication patches is provided.7/7/2015 9:20:33 AM3
Take Steps to Prevent Mix-ups with Pets' Medicines!123364010/9/2012 6:00:00 AMMedicationSafemedicationuse.caThis alert addresses the patient safety incidents that may occur if humans inadvertently take medications intended for their pets. A case is presented. A consumer reported that an elderly relative had accidently taken the family dog's deworming pills. A family member had placed the dog's pills on a bookcase. Later, the elderly relative moved the dog's pills to a bedside table, where other medicines were being stored. The elderly relative then took the deworming pills, instead of a regularly prescribed medicine, for several days. The mistake was discovered when it was time to give the dog a dose of deworming medicine. The family member found the empty container on the bedside table and realized that the elderly relative had taken all of the dog's pills. When the mistake was discovered, the elderly relative mentioned having felt sick for a few days earlier in the week, without knowing why. Fortunately, no serious harm occurred in this incident. However, some pets' medicines can be harmful if taken by humans. Also, a person who takes a pet's medicine instead of the medicine that was prescribed will lose the benefit of taking the correct medicine. Advice is provided to consumers on how to prevent mix-ups with pet medications stored in the home.7/7/2015 9:20:33 AM6
Narcotic Administration in the ED123485112/6/2012 7:00:00 AMCare ManagementWinnipeg Regional Health Authority (Canada)This alert describes a fatal patient safety incident involving a patient who presented to the emergency department (ED) with severe abdominal pain of two weeks duration and was prescribed morphine. Within the first hour of arrival the patient was triaged, placed in a treatment room, and assessed by a nurse. Based on the nursing assessment, the physician ordered/instituted a morphine protocol. Morphine was administered by nursing at regular intervals for pain control. The physician was made aware of the patient’s ongoing pain issues a few hours later. Approximately five hours after the patient’s arrival a nursing assessment revealed a distended abdomen. Following physician assessment and an abdominal xray, a perforated bowel was revealed. The patient deteriorated and was transferred to a tertiary hospital and underwent emergency surgery followed by admission to an Intensive Care Unit. The patient died three days later. Relevant findings and contributing factors included: - The ED had a high level of activity with carry over patients from the previous shift as well as a number of new patients during the shift. - There was one physician on duty and there had been a Code Blue just prior to the patient’s arrival. - There was no automatic trigger in the morphine protocol requiring the nurse and physician to discuss the patient and reassess the need for morphine. - It was unclear as to whether the nurse-to-physician communication regarding the patient’s ongoing pain requirements was conveyed and understood.7/7/2015 8:47:46 AM6
Behavioral Principles amd Strategies (BPS) -Updates12359626/22/2012 6:00:00 AMCare ManagementMaryland Office of Healthcare Quality (USA)This alert is an operational directive requiring updates to the Maryland Department of Health and Mental Hygiene Behaviour Principles and Strategies (BPS) curriculum with two changes shown in the recommendations section of this alert.7/7/2015 8:47:46 AM6
Events Associated with Prescribing, Dispensing and Administering Medication Loading Devices12370739/3/2012 6:00:00 AMMedicationPennsylvania Patient Safety Authority (USA)This alert discusses the potential patient safety incidents that may occur when working with loading doses of medication. A loading dose is an initial dose of medication administered to rapidly achieve therapeutic levels. The determination of a loading dose can be complicated, involving calculations dependent upon patient characteristics. This, combined with the need to also administer maintenance doses, creates complexity and opportunities for errors. From June 2004 through May 2012, Pennsylvania facilities reported to the Pennsylvania Patient Safety Authority 580 events associated with the prescribing, dispensing, and administering of medication loading doses, 15 of which were harmful events, including two events resulting in death. The most common types of events reported (in decreasing order) included “loading dose omitted or delayed,” “wrong loading dose given,” and “loading dose given multiple times.” A patient safety incident involving a wrong loading dose was the following: Physician ordered tigecycline 100 mg IVPB [IV piggyback] stat followed by an order for tigecycline 50 mg IVPB every 12 hours. According to the pharmacy, the doses were dispensed, but the RN [registered nurse] administered tigecycline 50 mg IVPB as the initial stat loading dose instead of the 100 mg bag. A patient safety incident involving a giving a loading dose multiple times was the following: Patient was admitted through the ED. Report was taken by charge nurse. The nurse in the ED did notify charge nurse that the patient had been given 1 mg loading dose of Dilaudid® prior to coming to the floor. Patient arrived to the floor, and there was a delay in patient getting put in the system by admissions. . . .Loading dose was administered a second time, as it was not marked off on floor orders. After being started on PCA [patient-controlled analgesia], patient was found to have low O2 [oxygen] saturations and had to be placed 6 L NC [nasal cannula]. The predominant medication associated with these reports was vancomycin . Phenytoin was the medication most frequently involved in harmful events. There were similarities in the types of events, frequency of the events, and medications involved in the events seen in Pennsylvania and the United Kingdom. Strategies to prevent errors associated with loading doses include developing standardized clinical guidelines on how to prescribe, administer, and monitor loading and maintenance doses; standardizing electronic and paper order sets and protocols; and including a thorough review of current drug therapy during patient handoffs. Specific strategies are described in the recommendations section of this alert entry.7/7/2015 9:20:34 AM4
Medication Double Message?12375835/10/2012 6:00:00 AMMedicationOregon Patient Safety Commission (USA)This alert addresses a patient safety incident that occurred when a patient did not fully understand the rationale for instructions for use of his high alert medication. A 76-year-old man on warfarin (Coumadin) was scheduled for a routine outpatient colonoscopy and was told to stop his Coumadin three days prior to the procedure. Because the patient was aware of his stroke risk and need to continue on the blood thinner, he did not stop the Coumadin. The colonoscopy was performed and was uneventful, but the patient had significant bleeding post procedure and needed admission to a hospital that evening. Recommendations to prevent similar patient safety incidents are provided.7/7/2015 9:20:34 AM3