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DispForm.aspx12794Communication"Prescribers should provide clear dosing instructions, avoiding phrases such as "use as directed". In consultation with the patient, choose a particular day of the week when the medication is to be taken, and specify this day on the prescription. However, avoid choosing Monday as the designated day, as this word has reportedly been misinterpreted as "morning". - Consider including the indication for methotrexate use on prescriptions, as helpful information for other health care providers (e.g., pharmacists and nurses). - When possible, for patients living in the community, consider limiting quantities to be dispensed to a one month supply at a time."ISMPC11Incidents of Inadvertent Daily Administration of Methotrexate6/4/2015 2:11:05 AM9
DispForm.aspx12797Communication"Inform clinicians/users that: a. When entering or editing numerical values on the programming screen, (e.g., dose rate, flow rate, volume to be infused) the numbers should be entered in their entirety, even if the previous numerical value exists on the screen or if a single digit was entered in error. b. All data entries should be verified before starting any infusions. c. If provided, Guardrails software soft-limit warnings should not be overridden without first verifying the rate they entered is what was ordered."VA44Cardinal Health’s Alaris System Infusion Pumps6/4/2015 2:11:05 AM3
DispForm.aspx12799CommunicationClear labelling of the sockets for essential power and message not to unplug the socket must be in place.HK015Incidental Unplugging of Power Supply of Essential Equipment in General Wards6/4/2015 2:11:05 AM
DispForm.aspx12804Communication"Good communication from the hospital providing the prescription for therapy to the hospital where treatment will be administered can help ensure advance planning for the patient visit. Different hospitals can have very different medication formularies. In this case the small urban hospital uses Solu-cortef more often than Solu-Medrol and nursing staff were therefore less familiar with the Solu-Medrol product. Ideally, in situations where an out-patient visit is scheduled, the required medication can be selected by pharmacy personnel in advance of the patient visit. A pharmacist-dispensed product provides an extra layer of safety."ISMPC37Depo-Medrol® Confused with Solu-Medrol®6/4/2015 2:11:05 AM
DispForm.aspx12810CommunicationCreate a Regional Advisory Committee that includes broad representation from all relevant sectors.WRHA19Delayed surgical specimen pick-up resulted in patient requiring an artificial skull plate6/4/2015 2:11:05 AM
DispForm.aspx12815Communication"That staff ensure when transferring patients that they identify all specific tracheostomy tube management issues, discuss these with the receiving ward acknowledging acceptance of patient care and document handover using the nursing handover sheet or equi"NSW19Reducing Incidents Involving Tracheostomy Tube Care6/4/2015 2:11:05 AM
DispForm.aspx12821Communication"Once standardized location for entry of allergy information has been determined, alert staff to always refer to these areas for reliable information."PA079Medication Errors Associated with Documented Allergies6/4/2015 2:11:06 AM3
DispForm.aspx12844Communication"Provide written information to the patient (e.g., product monograph, part III: Consumer Information), and review instructions with patients and/or patient’s family to ensure that important information is not overlooked and that they understand the risk of inappropriate handling of the product."PC49Transdermal Fentanyl: A Misunderstood Dosage Form6/4/2015 2:11:06 AM
DispForm.aspx12847CommunicationProvide a guideline for nurses with regards to when alternate care options may be suggested to patients presenting to an ED.WRHA41Patient with bacterial meningitis leaves an Emergency Department without being seen by ED physician6/4/2015 2:11:06 AM
DispForm.aspx12856Communication"Alert all staff that pass medication, that the devices that come in the box for liquid risperidone are considered pipettes by the company, although would normally be thought of as syringes by our frontline users. The markings are opposite of the syringes we are used to, and they are on the plunger of the pipettes. If possible, DO NOT USE THEM."VA03Risperidone oral medication syringe (pipette)6/4/2015 2:11:06 AM
DispForm.aspx12864Communication"An intervention be implemented to ensure that there is documentation to show that staff have informed patients about call bell use and that staff have ensured patients have a mechanism in place at all times to either call for or alert staff (i.e. call bell, bed sensor)."WRHA2A delayed diagnosis of a shoulder dislocation following an unwitnessed fall by an elderly patient receiving narcotics6/4/2015 2:11:07 AM
DispForm.aspx12873CommunicationEngage family members whenever they express concerns about their child’s behaviour—subtle changes may be more readily identified as abnormal by family members than by healthcare providers and thus can provide an invaluable source of assessment information.ISMPC45Hospital-Acquired Hyponatremia: Two Reports of Paediatric Deaths6/4/2015 2:11:07 AM
DispForm.aspx12874CommunicationObjective parameters for measuring pain poster operatively are important and allow for a smooth transition when a change in pain management occurs from postanesthesia to oral analgesia in home care. PA139Unanticipated Care After Discharge from Ambulatory Surgical Facilities6/4/2015 2:11:07 AM
DispForm.aspx12906CommunicationThe Facility Director (or designee) will ensure that all Dialysis staff and Biomedical Engineering staff are made aware of this Patient Safety Alert. VA55Possible blood contamination in hemodialysis machines6/4/2015 2:11:08 AM
DispForm.aspx12911CommunicationPharmaceutical manufacturers should modify ritonavir product monographs to include information about the fentanyl interaction and the need for close monitoring and reduction in the fentanyl dose if the two medications are used together.ISMPC30Drug Interaction Incident with HIV Post-exposure Prophylaxis6/4/2015 2:11:08 AM
DispForm.aspx12918CommunicationScheduled procedures may continue while the above actions are undertaken.VA16Connectors for Sterilization of all Gastrointestinal Fiberoptic Endoscopes6/4/2015 2:11:08 AM
DispForm.aspx12924CommunicationPractitioners can ask for an independent double-check for high alert drugs such as insulin.ISMPC22Insulin Errors6/4/2015 2:11:08 AM
DispForm.aspx12927Communication"Bring this bulletin to the attention of all nursing and pharmacy staff, and relevant committees such as Safe Medication Practices, or the Pharmacy and Therapeutics Committee. This will help raise awareness of the dangers of neuromuscular blocking agents."ISMPC16Neuromuscular Blocking Agents – Time for Action6/4/2015 2:11:08 AM
DispForm.aspx12928Communication"Redesign the Home Care Visiting Nurse File (Red) folder: for improved continuity of care and so that information can be found at a glance. A system that includes tabs to delineate sub-sections, i.e., doctors orders, medication sheets, narcotic counts, continuation notes, etc."WRHA31Inadvertent omission of part of trans-dermal Fentanyl patch dose led to admission of an elderly patient with a diagnosis of opioid withdrawal associated with delirium6/4/2015 2:11:08 AM
DispForm.aspx12932Communication"Share information about this problem as widely as possible, to increase awareness among healthcare practitioners, including pharmacy, nursing, and physician staff, as well as facility arrest teams (in all critical care areas, including the emergency department) and rapid response teams."ISMPC13Prefilled Syringes of Epinephrine and Compatibility with Intravenous Tubing6/4/2015 2:11:08 AM
DispForm.aspx12940Communication"If you have not already received and responded to this notice, immediately (within 24 hours) identify all units affected by this alert and contact Baxter at 1-800-843-7867, select 2 (for Technical Assistance) then 1 (for Colleague) to either arrange modification or obtain the insulators for installation by Biomedical Engineering."VA07Baxter Colleague Infusion Pumps6/4/2015 2:11:09 AM
DispForm.aspx12941CommunicationUse of EMR to guide hand-offs and shift report.ML010Healthcare Acquired Pressure Ulcers (HAPU)6/4/2015 2:11:09 AM3
DispForm.aspx12950CommunicationPain Management staff and/or the Chief of Staff’s office staff shall attempt to identify those patients with pumps that are fee based to outside providers.VA52Medtronic SynchroMed II Implantable Drug Infusion Pump; Models: 8637-20 and 8637-406/4/2015 2:11:09 AM3
DispForm.aspx12955Communication"Inform non-clinical staff, patients and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions."JC30Tubing misconnections—a persistent and potentially deadly occurrence6/4/2015 2:11:09 AM
DispForm.aspx12962CommunicationRevise communication protocols. JC14Preventing infant death and injury during delivery6/4/2015 2:11:09 AM
DispForm.aspx12963Communication"Your facility has received the letters and warning labels sent by Cardinal Health for the Alaris® SE infusion pumps, and that the warning labels have been appropriately affixed."VA32"All models of Alaris® SE infusion pumps - formerly the Signature Edition® Infusion System. Alaris is a subsidiary of Cardinal Health, Inc."6/4/2015 2:11:09 AM
DispForm.aspx12973Communication"Post a warning/list of specific patient items/implants that prohibit the use of MRI, including aluminized/foil-backed medication patches. This can be a helpful reference for both healthcare workers and patients."PC64Foiled Again! Risk from Transdermal Patches in MRI Procedures6/4/2015 2:11:10 AM
DispForm.aspx12977Communication"Patient Safety Manager (PSM) shall assure that this Alert has been addressed and the action status updated on the VA’s Hazardous Recalls/Alerts website,"VA43Medtronic InFuse Recombinant Human Bone Morphogenetic Protein in Cervical Spine Fusion6/4/2015 2:11:10 AM
DispForm.aspx12982CommunicationConsider cautionary auxiliary labels when high potency preparations are dispensed including when dispensed from a centralized IV admixture service.ISMPC01Narcotic Safeguards – The Challenge Continues6/4/2015 2:11:10 AM
DispForm.aspx12984CommunicationPatient Safety Manager shall document the status of this Patient Safety Alert on the VHA Hazardous Recalls/Alerts website. VA60"Hospital-grade power cords, manufactured by Electri-Cord and sold to medical equipment manufacturers"6/4/2015 2:11:10 AM3
DispForm.aspx12986Communication"Make sure that everyone knows where on the body the surgery should be, and that they speak up if something looks wrong."MN19Adverse Health Events Factsheet: Wrong-Site Surgery6/4/2015 2:11:10 AM
DispForm.aspx12992Communication"Practitioners are encouraged to report events related to infusion pumps when they occur to Health Canada Hotline, Infusion Pump Manufacturer and ISMP Canada voluntary medication incident reporting program."ISMPC33ALERT: Potential for “Key Bounce” with Infusion Pumps6/4/2015 2:11:10 AM
DispForm.aspx12995Communication"The circulating nurse will then conduct the time-out by audibly reading the following information from the patient's affirmation of informed consent: a. Patient name and medical record number b. Procedure c. Site of procedure (and level, if appropriate) d"MN20Time-Out Process in Minnesota6/4/2015 2:11:10 AM
DispForm.aspx13010Communication"Everyone has the duty and right to contribute to patient safety, therefore "speak up" where uncertainty or correct count occurs. "HK048Retained Gauze in Patients6/4/2015 2:11:11 AM
DispForm.aspx13020CommunicationEnsure all personnel who reprocess flexible endoscopes have read this Patient Safety Alert and the attachment. VA37Improper reprocessing of flexible endoscope biopsy valves6/4/2015 2:11:11 AM
DispForm.aspx13028Communication"Share learnings from this event with medical, pharmacy, and nursing staff to assure understanding of risk factors and best practices for prevention of phenytoin and fosphenytoin side effects, including purple glove syndrome. "OR14Purple Glove Syndrome6/4/2015 2:11:12 AM
DispForm.aspx13029Communication"Provide feedback, on-going monitoring."JC29Using medication reconciliation to prevent errors6/4/2015 2:11:12 AM
DispForm.aspx13040Communication"A warning must be appended to prepared doses of vinca alkaloids and in keeping with the Product Information, this warning should read “WARNING - For intravenous use only. FATAL if given by any other route”. Variation of this wording may produce inconsiste"PC73Policy for the Safe Administration of Vinca Alkaloid Drugs6/4/2015 2:11:12 AM
DispForm.aspx13041CommunicationClear guidelines wer established and documented for a minimum level of information that must be communicated when transferring patients between units.VIC033Potential for Error – communication and clinical handover6/4/2015 2:11:12 AM
DispForm.aspx13065Communication"Additional recommendations for prevention of transmission in healthcare settings can be discussed in consultation with your local health department, and can involve the Office of Health Care Quality or the Office of Epidemiology and Disease Control Programs as needed."ML003Acinetobacter Infections In Hospitals6/4/2015 2:11:13 AM
DispForm.aspx13067Communication"Regional representatives will develop a standard information-sharing process for patients being assessed/treated in other jurisdictions, e.g., design an integrated information-sharing form that would include the patient case history and the on call advice/instructions."WRHA50Undiagnosed Community-acquired MRSA in a pre-school child6/4/2015 2:11:13 AM
DispForm.aspx13068Communication"Directing users to ensure that sanitizer fully ePAporates from their hands before they touch devices, bed linens, or patients."PA0086/4/2015 2:11:13 AM
DispForm.aspx13085Communication"Have healthcare workers teach patients, family members, and visitors about effective handwashing techniques, as well as use of personal protective equipment if family is to become involved in incontinence care/toileting of an infected patient."PA031Clostridium Difficile: A Sometimes Fatal Complication of Antibiotic Use6/4/2015 2:11:13 AM
DispForm.aspx13090Communication"Educate patients on the proper use of patches, emphasizing the need to remove the old patch prior to applying a new patch."PC62Risk of Overdose from Multiple Transdermal Patches6/4/2015 2:11:13 AM
DispForm.aspx13092CommunicationDeveloping staff confidence through speak out' programs."VIC092Potential for Error – Procedure involving wrong patient or body part6/4/2015 2:11:13 AM3
DispForm.aspx13099CommunicationIncorporate Allied Health specialties' input into the Patient Care Plan and Falls Risk Assessment Tool.WRHA21Elderly patient on benzodiazepine and antipsychotic medications relocated to a different room and sustained a hip fracture6/4/2015 2:11:14 AM
DispForm.aspx13105Communication"Other actions (useful, but n to sufficient) include reviewing staff orientation content; sharing story among staff."PC98Risk from an Unusual Source6/4/2015 2:11:14 AM3
DispForm.aspx13108Communication"It should be emphasized to all dialysis personnel that the venous pressure monitor in the dialysis machine cannot always be relied upon for the early detection of a venous line disconnection or needle dislodgement. Of the patients reported with significant bleeding on dialysis, in only 2 instances were the dialysis venous pressure alarms known to have been overridden, inactivated, or defective."VA39Bleeding episodes during dialysis6/4/2015 2:11:14 AM
DispForm.aspx13119CommunicationDevelopment of a pharmacist-based counselling program to ensure that all patients with a positive result on HIT antibody assay are informed that they should obtain a Medic-Alert®" bracelet indicating that they have experienced thrombocytopenia with heparin. Ensure notification is sent to the family physician (and any other relevant physician) regarding the development of HIT while in hospital."PC47Heparin-Induced Thrombocytopenia – Effective Communication Can Prevent a Tragedy6/4/2015 2:11:14 AM
DispForm.aspx13126Communication"B. Pharmacy Information Manager (ADPAC) will identify patients currently on U-500 insulin with CPRS directions inconsistent with the ISMP recommendation and/or using U-100 insulin syringes. The list of patients will be given to the facilities Chief of Staff (COS). See bulletin for attachment. C. COS will assure that each patient identified in B above is seen by their prescribing clinic within 90 days and education is given to the patient of the appropriate insulin U-500 dose to use, the proper use of a tuberculin syringe and assure insulin orders are entered into CPRS consistent with the ISMP recommendation. See bulletin for attachment. A progress note documenting the education presented and the patient's understanding of the education must be entered into CPRS. "VA46Medication Safety- Insulin U-500 Safety Enhancements6/4/2015 2:11:14 AM