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Wrong site surgery/Interventional procedure Case 1: Local Anaesthetic (Lignocaine) was Injected to the Wrong Eye1182913310/1/2012 6:00:00 AMSurgeryHong Kong Hospital AuthorityThis alert describes a patient safety incident where the wrong site was operated on. A patient was admitted for elective repair of retinal detachment of the LEFT eye under retrobulbar anaesthesia. The operation site was marked above the patient’s LEFT eyebrow. Sign in and “time out” were performed by the surgeon and the nurse. The surgeon prepared the anaesthetic drug (2% lignocaine) and injected to the retrobulbar space of patient’s RIGHT eye instead of LEFT eye. The surgeon was informed that the anaesthetic drug was administered into the incorrect eye. The surgeon subsequently injected the anesthetic drug and performed operation on the patient’s LEFT eye. The patient’s RIGHT eye was assessed and no harm was detected. A contributing factor was that a long time lapse between “time out” and injection of local anaesthetic. Recommendations to prevent similar patient safety incidents are provided.7/22/2015 5:50:25 PM3
Drug Shortages Highlight the Need for Independent Double Checks12012302910/21/2013 6:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert advises on the need for heightened awareness and use of quality checks during drug shortages when new products are substituted for those not available to avoid patient safety incidents. One type of quality check is the independent double check, usually reserved for high-alert medications but appropriate in other situations. A specific incident is described. errors in the revision of a master formula for total parenteral nutrition (TPN) at a healthcare organization that led to neonates receiving amounts of trace elements that were greater than intended. Trace elements are chemicals that the body requires in only minute amounts, including, for example, zinc, selenium, and manganese. In the incident reported to ISMP Canada, the healthcare organization had responded to a shortage of its usual zinc product by revising the TPN master formula to accommodate a new zinc formulation with a different concentration. Calculation errors were made during this process but were not discovered until a few months later. Fortunately, it appears that no adverse effects have occurred. The use of independent double checks can be very useful when alternative products (such as those with different doses or concentrations) are introduced into standard or established processes. 7/7/2015 9:17:48 AM3
Sharing Opioid Medicines Can Be Deadly1225133109/3/2014 6:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert discusses the real and potential hazards of sharing medications used to treat pain, known as opioids, with someone who has not been prescribed the drug and descibes a relevant fatal patient incident. Opioids are prescribed specifically for individual patients after careful consideration of their age, weight, health conditions, allergies, and use of other medications. For this reason, an opioid prescription that is safe for one person can be dangerous for another person. Also, individuals who use opioids regularly can develop a tolerance to these medications. Over time, they may require higher doses to control their pain. In contrast, people who have never used an opioid may not tolerate even low doses. Warning signs that indicate someone may have received too much of an opioid medicine include a slow or unusual heart rate, shortness of breath, blue or purple lips or fingernails, inability to talk or be awakened from sleep, and heavy snoring or gurgling noises from the mouth or throat. In the incident, a man who suffered from chronic pain and died unexpectedly at home. Following his death, a patch containing fentanyl (a strong opioid medicine) was found on his body. This medicine had not been prescribed for him. The consumer’s spouse noticed the patch on his arm the night before he died. He told her that a friend had given him the patch. The coroner’s report concluded that using this patch in combination with alcohol caused the consumer’s unexpected death. Suggestions for both consumers and practitioners involved in the use of opioids are provided to reduce the likelihood of similar patient incidents.9/9/2015 11:16:16 AM3
Action Alert: The Coulds and Shoulds of MDVs and Spikes1219633619/29/2014 6:00:00 AMMedicationOregon Patient Safety Commission (USA)This alert discusses the patient safety incidents that could occur with the use of multi-dose vials and provides guidance on the best practices to avoid contamination and infection. Accessing medication in multi-dose vials with new needles each time can result in contamination. Some facilities are using a newer device, called a spike, which allows multiple doses of medication to be drawn out without having to penetrate the vial diaphragm multiple times. The alert references the “One & Only Campaign” and the Joint Commission toolkit to encourage best practices in the safe handling and use of needles, syringes, needleless devices, cannulas, and spikes that replace needles, as well as practices related specifically to MDVs. Best practice recommendations are provided in the alert for use of multi-dose vials.9/9/2015 11:16:12 AM20
Cerebrospinal Fluid (CSF) Sample Transport1227633787/13/2015 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 PM16
Packaging and Labelling Are at Root of Many Medication Errors11649CPSO018/1/2010 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 drivers11652NPSA03112/16/2010 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
Overdose of intravenous paracetamol in infants and children11656NPSA04710/29/2010 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
Analysis of harmful medication incidents involving psychotropic medications11722263/1/2012 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert discusses patient safety incidents involving psychotropic medications by patients in the community, long term care and hospital settings. Information is shared about incidents involving psychotropic medications that have been voluntarily reported to ISMP Canada, specifically incidents related to the following categories of drugs: antidepressants, antipsychotics, benzodiazepines, anxiolytic-sedative-hypnotics, and antimanic drugs. The bulletin includes an overview of incidents with an outcome of harm or death and highlights the major themes identified through an aggregate analysis. Specific incident examples are provided, along with contributing factors and opportunities for systembased improvements. Of the 79,539 incidents in the ISMP Canada database, including near misses and hazardous conditions, 5850 (7.4%) involved psychotropic medications. Of these 5850 medication incidents, 137 (2.3%) were associated with an outcome of harm. Qualitative analysis of the 133 incidents identified a number of recurrent themes, which were classified according to 3 main practice settings: community, longterm care, and hospitals. The themes for each setting were associated with certain contributing factors, provided in detail in the alert. Common themes among all practice settings were: multiple medications, incorrect patient and incorrect dose. Incorrect medication was a common theme in the community and hospital setting. Transitions of care, dose omission and change of order were themes identified in the hospital setting only. Recommendations to prevent similar patient safety incidents are provided.7/7/2015 9:17:41 AM3
ALERT: Additional Safeguards Required for New Succinylcholine Product, a Neuromuscular Blocking (Paralyzing) Agent117283112/20/2012 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert advises readers of a new neuromuscular blocking agent that does not have the standardized warning printed on the vial cap and vial ferrule; this change can contribute to serious and/or fatal patient safety incidents. Neuromuscular blocking agents, also known as paralyzing agents, are high-alert medications. Serious injuries and deaths have occurred with substitution errors involving these drugs. Over the past 10 years, efforts by Canadian drug manufacturers have resulted in the development of a standardized warning, which is printed on the vial cap and/or vial ferrule. The warning states, "Warning: Paralyzing Agents". The United States Pharmacopeial (USP) Convention now includes this requirement for neuromuscular blocking agents within their standards for packaging and labelling of injectables. A new neuromuscular product, succinylcholine, manufactured by Alveda Pharmacy, has entered the Canadian market without the warning on the cap or ferrule. Since institution of the warning on previously available products, practitioners who inadvertently select a neuromuscular blocking agent in place of another drug have been presented with a prominent warning in a unique location on the drug packaging, at a critical point in the medication-use process, i.e., when the practitioner is removing the cap and withdrawing the medication from the vial. Presence of the warning on the cap and ferrule has been documented to prevent the inadvertent administration of succinylcholine. Now that practitioners are familiar with this warning, switching to a neuromuscular blocking agent that lacks the warning on the cap and ferrule could lead to confusion and substitution errors. Hence, ISMP Canada has contacted Alveda Pharma, and the company is exploring the feasibility of adding the standardized warning to the cap and ferrule of its succinylcholine product. Recommendations to address the presence of this new product are provided.7/7/2015 9:17:41 AM19