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Retained Consumables and Instruments - Catheter Tip Cut and Retained in Newborn's Intestine1211331914/1/2014 6:00:00 AMCare ManagementHong Kong Hospital AuthorityThis alert discusses a patient safety incident of retention of a foreign body following an invasive procedure. The specific incident is described. A premature newborn developed respiratory distress after birth and was intubated. Surfactant treatment was given via a multi-access catheter designed for accessing the airway. After endobronchial administration of the surfactant, the case doctor retracted the catheter from the endotracheal tube (ETT). Residue surfactant inside the catheter was observed and so the catheter was re-inserted into the ETT and the residue was flushed. When the ETT position was found satisfactory, the excessive length of ETT was cut. Staff were not aware that the catheter was not completely retrieved at the time of ETT cutting. 0n the next day, X-ray imaging revealed that a suspected fragment of catheter was retained. The 18 mm catheter was expelled with faeces uneventfully after 12 days. Key contributing factors in this incident were the following: 1. Lack of a standardized guideline on ETT shortening and surfactant administration. 2. Ineffective communication between doctors and nurses. Recommendations to prevent similar patient safety incidents are provided.7/7/2015 8:47:51 AM3
Change to Handwritten Prescription Leads to Dose Misinterpretation12021302010/20/2013 6:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert describes a patient safety incident of a medication error where due to an overwrite by the prescriber, the patient received the wrong dose. A physician wrote a medication order for a patient who needed analgesia for pain. After writing the prescription for “morphine 1 mg”, the physician changed the order by writing the number “2” over top of the “1” in the dosage. As a result, the order was misinterpreted asb“morphine 8 mg”. The patient received several doses at quadruple the intended amount beforebthe error was identified and corrected. The patient did not experience any harm, although additional monitoring was required. A recommendation to reduce the likelihood of such an error is provided.7/7/2015 9:17:49 AM3
"Changing technology, changing risk Upgrading from 1.5 to 3.0 Tesla MRIs"12384OR08Diagnostic ImagingOregon Patient Safety Commission (USA)A ventilator was pulled into the core of a 3.0 Tesla MRI. The ventilator was being moved in prior to the patient being brought into the room. The ventilator was previously tested and rated as acceptable for use in the MRI environment." This alert describes actions to reduce risk."7/7/2015 9:08:21 AM3
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
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
Narcotic Administration in the ED117505112/6/2012 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 AM3
Events Associated with Prescribing, Dispensing and Administering Medication Loading Devices11772739/3/2012 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?11777835/10/2012 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