|"AEDPlus Public Access Automated External Defibrillators (AEDs), manufactured by Zoll."||13487||VA47||3/1/2009 7:00:00 AM||Device||National Center for Patient Safety (Department of Veteran's Affairs - USA)||"The affected defibrillators’ batteries can have a shorter than expected life, expiring after three years, rather than five. When used in defibrillation, the device may verbally prompt users to “change batteries” and fail to deliver therapy. There will be no prior warning of the failure. This alert affects all AEDPlus defibrillators sold before March 2009. The AEDPlus is distributed in many areas, both clinical and administrative. Additionally, they are distributed to VA in general, including VACO, VBA, VCA and OI&T offices. The Alert describes actions to be implemented by applicable VA facilities. "||7/7/2015 9:07:36 AM||11||http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Choosing Correct Syringe Size- Medfusion Syringe Pump||12879||3491||1/6/2016 7:00:00 AM||Device||Alberta Health Services||This alert addresses the potential patient safety incidents of wrong dose of medication delivered via a syringe pump related to size of syringe used.
The Medfusion syringe pump is able to automatically detect syringe size for all the syringes except for the 1 mL and 3 mL BD syringes because the barrel diameters are identical in size. This creates a risk of under or over infusion and relates to Smiths Medical Medfusion syringe pump (models 3500 & 4000).
Recommendations to prevent incidents of wrong infusion are provided.||9/1/2017 8:55:38 PM||9||http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Action Alert: Colonoscopies and Red Dot Alerts for Anticoagulants||12791||3364||1/30/2015 7:00:00 AM||Surgery||Oregon Patient Safety Commission (USA)||This alert discusses the risk of bleeding in patients undergoing colonoscopies who are on anticoagulants and who have removal of large polyps. The use of an alert system to identify anticoagulated patients is described along with the decision not to remove large polyps in this patient population during the colonoscopy.
Recommendations for optimal care of patients on anticoagulants scheduled for colonoscopies are provided.||9/9/2015 11:16:12 AM||23||http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Review of the Infection Prevention and Control and CSR Sterilization Issues in East Central Health Region||12636||3144||7/1/2007 6:00:00 AM||Infection Control||Health Quality Council of Alberta||A rural secondary healthcare facility closure was precipitated by evidence of inadequately sterilized medical equipment and an inability to contain an ongoing spread of Methicillin Resistant Staphylococcus aureus (MRSA). At the request of Alberta Health and Wellness, the HQCA conducted an independent and systematic review with respect to infection prevention and control (IPC) and central sterilization room (CSR) processes. The scope of the review was expanded to include other sites within the same regional health authority.
The following themes emerged as contributing factors relating to the inappropriate sterilization of medical equipment in the CSR and inability to contain the MRSA transmission in the hospital.
• clarity of authority, accountability, and responsibility of the hospital and the regional health authority and its management
• organizational structure and processes to support safety and quality
• patient safety culture and impact on planning, operations, decision-making
• application and implementation of best practices, standards, policies and procedures and mechanisms to ensure compliance of same
• processes to define expectations and evaluate knowledge, competency and skills
• support of continuing education, training and professional development
• engagement of physicians in safety and quality
• equipment and physical plant limitations
• human resource requirements for effective infection prevention and control
• provincial leadership for infection prevention and control
• role of and educational requirements for the board members especially in patient safety and quality leadership
A total of 76 recommendations were made; abbreviated versions are presented in this alert.||7/7/2015 9:11:36 AM||3||http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|The Risk of Toxicity from Topical Anaesthetic Products||12867||3294||9/18/2014 6:00:00 AM||Medication||New South Wales Department of Health (Australia)||This alert discusses the patient safety incidents of systemic toxicity from application of topical anaesthetic products. These products frequently contain lignocaine (lidocaine) or amethocaine (tetracaine) and may also contain vasoconstrictors such as phenylephrine or adrenaline (adrenalin).
Lignocaine is used widely in clinical practice and under normal conditions, systemic absorption is generally insufficient to cause major toxicity. However, severe lignocaine toxicity has been reported and remains a possibility particularly in susceptible people such as those with cardiac disease, the young or eldery and debilitated individuals.
Toxic reactions with both lignocaine and amethocaine can include central nervous system effects such as dizziness, confusion and loss of consciousness as well as cardiac effects including hypotension, bradycardia and cardiac arrest.
Sympathomimetics, phenylephrine and adrenaline are frequently included in local anaesthetic products to cause local vasoconstriction, reducing systemic absorption of the local anaesthetic and prolonging its duration of action. Excessive topical application of phenylephrine has been associated with cardiovascular side effects, including myocardial infarction.
Contributing factors to high systemic absorption and toxicity of topical anaesthetics with or without vasoconstrictors include the following:
- Use of excessive quantities;
- Application to irritated or broken skin, or traumatised mucosa;
- Extended duration of use;
- Short intervals between application of doses;
- Application to large areas of the body; and
- Using occlusive dressings or wrappings on areas where lignocaine is applied.
The alert provides recommendations to minimize risk of systemic absorption and toxicity in the use of topical anaesthetics.||5/31/2017 7:45:14 PM||3||http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Non-luer spinal (intrathecal) devices for chemotherapy||12735||3169||2/20/2014 7:00:00 AM||Device||NHS Commissioning Board||This alert provides a directive for use of non-Luer connectors when administering chemotherapy by the intrathecal route. It provides new guidance on spinal (intrathecal) devices for chemotherapy that replaces guidance in previous alerts NPSA/2009/PSA004A and NPSA/2011/PSA001.
Deaths and severe harms have occurred in the NHS and worldwide from the wrong route administration of intravenous chemotherapy by the spinal and intrathecal route. In order to minimise risks of wrong route administration the former National Patient Safety Agency (NPSA) issued two alerts (2009, 2011) recommending the use of new connectors, that cannot connect with intravenous Luer or infusion device connectors, for spinal (intrathecal), epidural and regional clinical procedures, when suitable devices became available. Trusts should be aware that non-compliance with the patient safety alert could be taken into account when considering whether an adverse outcome constitutes a breach of the Care Quality Commission (Regulated Activities) Regulations 2010 and could lead to regulatory action, including by other agencies.
Full compliance with previous NPSA alerts in anaesthetic and non-chemotherapeutic practice is currently not possible, as the range of non-Luer and infusion devices for spinal, epidural and regional procedures remains incomplete. Continued use of Luer devices should be recorded in the organisation’s risk register, with additional safety precautions taken and suitable safer devices introduced into practice as soon as they are available.
Recommendations to prevent wrong route administration of intrathecal chemotherapy are provided.||7/7/2015 9:06:22 AM||3||http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Check Labels Carefully When Selecting Gravol Products!||12331||36||5/4/2012 6:00:00 AM||Medication||SafeMedicationUse.ca||This 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 AM||3||http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Alert: Take Care with Medicine Patches!||12334||38||7/4/2012 6:00:00 AM||Medication||Safemedicationuse.ca||This 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 AM||3||http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Take Steps to Prevent Mix-ups with Pets' Medicines!||12336||40||10/9/2012 6:00:00 AM||Medication||Safemedicationuse.ca||This 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 AM||6||http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Narcotic Administration in the ED||12348||51||12/6/2012 7:00:00 AM||Care Management||Winnipeg 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 AM||6||http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|