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 CPSI News



Do your meds get along?3372512/11/2018 9:12:59 PMPatient Safety News;Patient & Family stories ​Are you at risk of harm from your medications? If you – or people you love – are over the age of 65, there is an increased risk of complications from taking prescription, over-the-counter, or naturopathic drugs. In 2016, one out of 143 Canadian seniors were hospitalized due to harmful medication interactions. Two out of three Canadian seniors take at least five different prescribed medications; one out of four takes at least ten! More than one in three Canadian seniors use at least one potentially inappropriate medication, which can lead to health risks, including falls, fractures, hospitalizations and death. Johanna Trimble with MP Mark Strahl (Chilliwack-Hope), Allison Kooijman (Co-chair of Patients for Patient Safety Canada) and Ioana Popescu (Canadian Patient Safety Institute) Healthy, strong and independent, 87-year-old Fervid Trimble became ill with an apparent flu. She was transferred to a healthcare centre to recuperate, but her family witnessed rapid cognitive decline including delusions, hallucinations and inability to recognize family members. Newly prescribed pain medications and an anti-depressant were to be followed by a medication to treat Alzheimer’s. It took months to convince the medical staff to review and sharply revise her medications. Fervid recovered cognitively, giving her four more years to enjoy with her family. However, the adverse drug reaction left her bed-ridden for months. Her mobility compromised, she required a wheelchair and could not return to independent living in the apartment she loved. Fervid was later subjected to repeated courses of antibiotics for suspected urinary tract infections that were likely adverse effects of the culprit drugs. She contracted C. difficile, an antibiotic-resistant diarrheal infection for which more powerful antibiotics were given, which compromised her health and led to her decline. Her daughter-in-law, Johanna Trimble of Patients for Patient Safety Canada (PFPSC), has since joined several patient groups to advocate for elderly patients in the healthcare system. “Each year, 50% of medications are taken incorrectly and an estimated 37% of seniors in nine provinces receive a prescription for a drug that should not be taken by this population,” says CEO Chris Power of the Canadian Patient Safety Institute. “Our focus for this year’s Canadian Patient Safety Week was to encourage patients and healthcare providers to have an open conversation about medication risks.” The issue isn’t limited to prescription medications. In a recent PFPSC survey, 30% of respondents said that they had purchased the wrong natural health product, homeopathic, or over-the counter drug. In response to their concerns, PFPSC is calling for clearer information and larger size lettering on product labels. “Consumers want to know what's in the products they’re taking,” says Maryann Murray, PFPSC. “Just like food products, all labels should be written in plain language, list all ingredients, and be printed in a legible size.” During Canadian Patient Safety Week, PFPSC submitted a petition in the House of Commons to support consistent, plain-language labelling. Sponsored by MP Daniel Blaikie, the petition calls on the Minister of Health to ensure that the regulations for non-prescription drugs and natural health products address these important patient concerns. Click here to sign this petition by January 31, 2019. At the same time, 13 patients from across Canada travelled to Ottawa to meet with 31 Members of Parliament and Senators. They spoke about their personal experiences with patient harm and asked for their representatives’ support in making Canada’s healthcare system safer. We thank the following representatives for their time and their commitment MP Dean Allison (Con), Niagara West (ON) MP Mel Arnold (Con), North Okanagan-Shuswap (BC) MP Daniel Blaikie (NDP), Elmwood-Transcona (MB) MP Celina Caesar-Chavannes (Lib), Whitby (ON) MP Bill Casey (Lib), Cumberland-Colchester (NS), Chair Standing Committee on Health MP Shaun Chen (Lib), Scarborough North (ON) MP Don Davies (NDP), Vancouver Kingsway (BC), Vice-Chair Standing Committee on Health MP Kerry Diotte (Con), Edmonton Griesbach (AB) MP Terry Duguid (Lib), Winnipeg South (MB) MP Julie Dzerowicz (Lib), Davenport (ON) MP Hon. Diane Finley (Con), Haldimand-Norfolk (ON) MP Marilyn Gladu (Con), Sarnia-Lambton (ON), Vice-Chair Standing Committee on Health MP Raj Grewal (Lib), Brampton East (ON) MP Kent Hehr (Lib), Calgary Centre (AB) MP Robert Kitchen (Con), Souris-Moose Mountain (SK) MP Hon. Kellie Leitch (Con), Simcoe-Grey (ON) MP Elizabeth May (Green), Saanich-Gulf Islands (BC) MP Ron McKinnon (Lib), Coquitlam-Port Coquitlam (BC) MP Marco Mendocino (Lib), Eglinton-Lawrence (ON) Senator Mohamed-Iqbal Ravalia, Newfoundland and Labrador Senator Jim Munson, Ontario MP Geoff Regan (Lib), Halifax West (NS) MP Raj Saini, (Lib), Kitchener Centre (ON) MP Sonia Sidhu (Lib), Brampton South (ON) MP Mark Strahl (Con), Chilliwack-Hope (BC) MP David Tilson (Con), Dufferin-Caledon (ON) MP Dave Van Kesteren (Con), Chatham-Kent-Leamington (ON) Senator Frances Lankin, Ontario Senator Elizabeth Marshall, Newfoundland and Labrador Senator Lucie Moncion, Ontario Senator Kim Pate, OntarioEach of these representatives, and everyone who participated in Canadian Patient Safety Week, were advised on ways they could keep themselves and their loved ones safer. Review your medications with a doctor, nurse or pharmacist if you are, or someone you love is over the age of 65, taking 5 or more medications, recently discharged from hospital, or concerned about side effects. Use the 5 Questions to Ask About Your Medications with your doctor, nurse, or pharmacist; when going home from hospital; or when visited by home care services. To reduce the risk of medication harm, consider these 5 tips 1. KNOW Keep a list of all medications – prescription, over-the-counter, naturopathic, and recreational – and take it with you to all medical appointments to reduce the risk of harmful drug interactions. 2. CHECK with your pharmacist, doctor, or nurse to confirm all medications are being taken properly. 3. ASK to review ALL of your meds when your doctor starts, stops, or changes any of your meds. 4. REVIEW your medications with your pharmacist when filling or refilling a prescription, and when adding, removing or changing any non-prescription medication or supplement. 5. CONSULT your doctor or healthcare professional before STOPPING OR CHANGING any medication. To learn more about medication safety, download these tools at • When should you have your medications reviewed? • What are 5 Questions to ask about your medications? • Fill out your medication list – for safety’s sake! Petition for plain-language labeling Sign the petition 12/11/2018 9:00:00 PM Are you at risk of harm from your medications? If you – or people you love – are over the age of 65, there is an increased risk of complications12/11/2018 10:53:29 PM98
Patient Safety Power Play-Three Things I’ve Learned This Year2515112/11/2018 8:12:43 PMPatient Safety Power Plays Last month, we celebrated some of the amazing accomplishments we and our partners achieved this year. While I was sharing them, I thought about the lessons I learned. It is so easy to get wrapped up in the daily routine of meetings, presentations, and planning that it can be hard to stop and think about the progress we’ve made together. We were incredibly excited about the successes we saw this year with the Canadian Patient Safety Week. Not only did we roll out a program that interested our primary audience of healthcare leaders and providers, but we also engaged with the public in ways we never had before. Our tools for medication safety were downloaded by people across the country and around the world. By reaching outside the healthcare system, we spread the message of medication and patient safety farther than ever. The lesson here is not to be afraid to try something new. If we hadn’t decided to engage with new audiences among the general public, we would not have been able to spread our messages so far, let alone equip so many people with tools they can use to keep themselves safer. CPSI has a strong history of supplying our healthcare partners with patient safety messages and tools – but we can make even more of a difference if we remember to try new ways of reaching out to millions of Canadian patients and families out there who need to know how to keep themselves safer in our healthcare system. The second success we celebrated this year involved our introduction of the first of four Safety Improvement Projects Measuring and Monitoring for Safety. The project is under way, with participating teams from across Canada, and we will share some of their stories in an upcoming edition of our Digital Magazine. The other three Safety Improvement Projects – Teamwork & Communication, Medication Safety, and Enhanced Recovery After Surgery – will launch next month, and we invite you to sign up here to learn about them as soon as they are announced! The lesson we learned at CPSI this year was to focus on what we do best. We are a small and passionate group of people. With the support of our partners, we have the daunting task to improve patient safety results for a national healthcare system involving thousands of people across hundreds of locations. When we focus on the expertise that is unique to our organization, we can start making improvements to patient safety… right now! Finally, we celebrated our partnership with Health Canada. While we were very proud to help deliver a community engagement event in Halifax on the implementation of national pharmacare, we are also working closely with the other Pan-Canadian Healthcare Organizations (PCHOs) and health ministries across the country to make patient safety a priority. I have met with Ministers and Deputy Ministers of most of Canada’s provinces and territories. I have discussed how to work with other healthcare organizations. And I have made sure that each meeting concludes with a commitment to making patient safety one of the most important elements of our healthcare system. The lesson here is obvious, and probably the most important one if we work with our partners, we can achieve great things. By uniting with Health Canada and regional health ministries, we can make sure that patient safety becomes a priority across the country. By working with other PCHOs, we can build synergies to achieve our goals together. By working with Patients for Patient Safety Canada, other patient organizations, and Quality Improvement groups across the country, we can help equip patients and their families to take an active role in their healthcare experiences. All of these will be to the overall improvement of our health and our healthcare system well into the future. Try new approaches. Focus on our strengths. Work together. Learning these three lessons has been key to our plans for a successful 2019, where we intend to make Canadian healthcare systems safer for all patients today, tomorrow, and in the tomorrows to come. Happy holidays to you and yours, be safe, and I’ll talk to you in the new year. Questions? Comments? My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 12/11/2018 8:00:00 PMLast month, we celebrated some of the amazing accomplishments we and our partners achieved this year. While I was sharing them, I thought about the12/11/2018 8:45:12 PM75
Measuring hospital harm to improve patient care and optimize patient outcomes3370812/4/2018 9:27:48 PM ​Patients expect hospital care to be safe, and for most people it is. However, a recent study showed that patients experienced potentially preventable harm in more than 138,000 hospitalizations or about 1 in 18 hospitalizations (this does not include hospitalizations in Quebec). Key findings from the Measuring Patient Harm in Canadian Hospitals report, which was released by the Canadian Institute for Health Information (CIHI) and the Canadian Patient Safety Institute (CPSI), showed that the five most common types of harm, making up 51 per cent of all harmful events, were electrolyte and fluid imbalance, urinary tract infections, delirium, anaemia-haemorrhage, and pneumonia. It was estimated that patients who experienced harm spent a total of more than half a million additional days in hospital – that is more than 1,600 beds each day, or the equivalent of approximately four large hospitals occupied over a year. The associated hospital cost (excluding physician fees, follow-up care, and readmission) was about $685 million. The Hospital Harm measure identifies acute care hospitalizations with at least one occurrence of unintended harm (during the hospital stay) that could have potentially been prevented by implementing known evidence-informed practices. The measure is comprised of 31 clinical groups that fall under four categories. The Hospital Harm measure complements other patient safety information available to hospitals, including patient safety incident reports, patient experience surveys, chart reviews or audits, infection control data, global trigger tools, and clinical quality improvement process measures. Combined, this information can inform and optimize improvement initiatives. The Hospital Harm Improvement Resource was developed by the Canadian Patient Safety Institute to complement the CIHI Hospital Harm measure. It links measurement and improvement by providing evidence-informed practices that support patient safety improvement efforts. The online Improvement Resource is a compilation of evidence-informed practices linked to each of the 31 clinical groups within the Hospital Harm measure to help drive changes that will make care safer. Through extensive research and consultation with clinicians, experts and leaders in quality improvement (QI) and patient safety, the Improvement Resource is intended to make information on improving patient safety easily available, so teams spend less time researching and more time optimizing patient care. The Improvement Resource includes a summary of evidence-informed practices that reduce the likelihood of harm, and suggested measures for outcomes and processes. For example, evidence-informed practices for Delirium include developing a standardized protocol for preventing or managing delirium, including identifying and treating underlying causes; implementing non-drug strategies such as early mobility; implementing environmental strategies such as visible daylight; and reassessing sedation daily. For Medication events the evidence includes conducting an organizational Medication Safety Self-Assessment; implementing medication reconciliation and high-alert medication safety processes; and improving core processes for ordering, dispensing and administering medications. Also included in the resource are patient stories, success stories, standards and required organizational practices associated with each clinical group. The Improvement Resource is a dynamic tool that the Canadian Patient Safety Institute will continue to update as new tools and approaches are developed and more evidence-informed practices emerge. The hospital harm project aims to provide health system leaders with better information on patient safety and support patient safety improvement efforts. Armed with evidence-informed practices compiled through continued research efforts and united through collaboration, clinicians, hospital staff and patients can all play a role in improving safety in Canadian hospitals. For more information, visit or 12/4/2018 8:00:00 PMPatients expect hospital care to be safe, and for most people it is. However, a recent study showed that patients experienced potentially preventable12/7/2018 3:31:02 PM634
Building quality and patient safety capacity in Atlantic Canada3369911/27/2018 4:54:24 PMSuper SHIFTERS ​#SuperSHIFTERS Debbie Molloy and Colin Stevenson are Co-Chairs of the Atlantic Health Quality and Patient Safety Collaborative. The Collaborative aids in knowledge exchange and provides advice and recommendations to the Atlantic Deputy Ministers of Health for the purpose of advancing quality improvement and patient safety across Atlantic Canada. (Colin Stevenson and Debbie Molloy) What is the role of the Atlantic Health Quality and Patient Safety Collaborative? The Atlantic Health Quality and Patient Safety Collaborative (AHQPSC) is a collaboration across the health system in the four Atlantic Provinces New Brunswick, Newfoundland and Labrador, Nova Scotia, and Prince Edward Island. The focus and purpose of the AHQPSC is to help us to advance patient safety knowledge and initiatives across our jurisdictions -- to build capacity, foster relationships and share information, knowledge and expertise. The Collaborative was created by the Ministries of Health from the four Atlantic Provinces in 2010, to help us learn from each other. The Steering Committee is comprised of 13 members, with three representatives from each of the four Atlantic Provinces (two come from the health system and one from the provincial Health Ministry), and a local member of Patients for Patient Safety Canada that sits as the patient and family representative. We have a strong partnership with the Canadian Patient Safety InstituteCanadian Patient Safety Institute (CPSI), who act as the secretariat and provide a myriad of support and continuity to the AHQPSC. The work of the AHQPSC is funded through a biennial grant provided by the four provincial Health Ministries.What are some of the key initiatives that the Collaborative has undertaken? Our hallmark event is to host the Atlantic Learning Exchange (ALE). One of the four Atlantic provinces hosts the Conference every second year, with support for planning coming from all members of the Collaborative. With CPSI at the table, we add national and international perspectives on the advancement and improvement of safety and patient care. The ALE is an opportunity to talk about what is happening in each province and to recognize and celebrate patient safety initiatives across Atlantic Canada. The next ALE will take place in St. John's, Newfoundland on October 8-9, 2019. This will be our fifth conference and we welcome everyone interested to come and learn more about our work. On a pan-Canadian scale, the AHQPSC was an active and committed partner for the National Patient Safety Consortium and the Integrated Patient Safety Action Plan, with representation at the Consortium table and on the Action Teams for each of these priority areas. Through the Collaborative, members from Atlantic Canada have also actively supported actions from the Surgical Care Action Plan and contributed to the evaluation of the Consortium and Integrated Patient Safety Action Plan. The Collaborative has made an investment in patient safety and quality training. We have offered incident management skills training; hosted a Canadian Patient Safety Officer Course in a combination of online and in-person formats; provided disclosure training in cases of adverse events; and introduced the TeamSTEPPS Canada™ program to improve teamwork and communications. By investing in these types of training, we have been able to advance the skill level of a large group of people within each of our respective provinces. This would not have been achievable as individual jurisdictions. In terms of resource materials, the Collaborative was involved in the development of a patient engagement framework in partnership with the Canadian Patient Safety Institute and Health Quality Ontario. The Engaging Patients in Patient Safety – A Canadian Guide was first launched at the ALE in Prince Edward Island in 2017. Earlier this year, the Collaborative assisted with revising the guide. This extensive resource is based on evidence and leading practices and aims to help patients and families, patient partners, providers, and leaders work together more effectively to improve patient safety. One of our current priorities is supporting a 12-month virtual collaborative around patient engagement in patient safety and quality improvement. In the past, our collaboratives have taken an in-person format, so this is an opportunity to try something new. The virtual collaborative was launched in September 2018 with 17 teams from the four Atlantic Provinces participating. Over the next year, teams will receive coaching on how to improve patient engagement, learn new strategies, and work together as a larger community to ensure we are at the top of our game in terms of patient engagement.What makes the Collaborative unique and innovative? The Atlantic Provinces have taken a multi-provincial approach in building relationships and seeking opportunities to collaborate on patient safety initiatives. This makes us unique in Canada. We come together to identify priorities and pool our resources to produce results that can be utilized across Atlantic Canada. We aren't aware of any other jurisdiction that has seen this type of cross-province success in their partnerships. What makes the Collaborative successful is that we have been able to go explore areas that may not have been given the same amount of thought if we had all been working independently. We have been able to tackle priorities together; we may be at different places along the road, but we are able to work on priorities that are important to all of us. This strong collaboration facilitates the sharing of ideas and learning across all of Atlantic Canada, which has proved to be effective, efficient, and also ensures standardization across the jurisdiction. In terms of value and how we do our work, we have representation from all four provincial Health Ministries sitting at the table, along with the delivery arm of the system, to have conversations and establish priorities. We sit at the table together, share information and develop an approach to take us along the patient safety journey.What learnings or takeaways has the Collaborative provided for you? Debbie For me personally, gaining an in-depth understanding of both patient safety and quality improvement has been very beneficial. Being part of the Collaborative has also offered a different level of thinking and learning around how to engage patients and the value of having the patient and client at the table. Colin In healthcare, or otherwise, it is important that we have alignment within more than one province. We have been able to identify some truly remarkable things to focus on, targeted our resources to develop them together, and put them into use across the four Atlantic Provinces. We don't often see such success in working across provincial boundaries. This was an eye-opener for me. We have seen progress and we all continue to have a commitment to the work we are doing together across the Atlantic Provinces.Is the Collaborative a model that others could replicate? At the end of the day, it is about finding the common ground, something that all parties are interested in advancing together. We have been able to tap into the expertise and knowledge of CPSI, which is very helpful. We are not big provinces, and at times it is a bit of a lonely space to be in. You can't always look at other jurisdictions and feel like you are talking to someone who is similar to you, which is an advantage that we are grateful to have at the Collaborative table. The fact that we have a pan-Canadian partner who has the knowledge and processes to support and bring people together is a huge advantage. We have had great success in our partnership with the Canadian Patient Safety Institute. When people are coming together on their own it can be a bumpy road, but if you leverage a partner to help you identify opportunities, it certainly makes the journey easier. Where can our readers go to learn more? We are happy to lend our expertise nationally! Contact us at Colin Stevenson has over 20 years of healthcare management and leadership experience, working in both the private and public sector with roles in facilities management consulting, long term care, health authority operations and project/transformation management. As the Vice President of Quality and System Performance with the Nova Scotia Health Authority, Colin is responsible for leading the development and implementation of strategic plans, goals and objectives to support the delivery of provincially integrated health programs and services; and ensuring there are structures, systems and processes in place to enable the Nova Scotia Health Authority to achieve the best outcomes in health care program and service with a focus on quality, performance and patient safety. Colin is a graduate of the Health Administration program of Dalhousie University and a Certified Health Executive (CHE) with the Canadian College of Health Leaders. Debbie Molloy is a human resources professional with 20 years of experience in the healthcare, energy and hospitality industries. She has worked in both the public and private sectors and brings a broad understanding of the challenges and opportunities facing health care in today's environment. Her career path has allowed her to develop expertise in the areas of organizational effectiveness, talent management and employee relations. Beyond human resources she has also a solid background in quality improvement and patient safety. At Eastern Health, Debbie has had executive responsibility for a number of programs including Human Resources, Quality, Patient Safety and Risk Management, Infection Prevention and Control, Occupational Health, Protection Services and the Centre for Nursing Studies. Debbie holds both a Bachelor of Commerce (Co-operative) and Masters of Education (post-secondary studies) from Memorial University.11/27/2018 4:00:00 PM #SuperSHIFTERS Debbie Molloy and Colin Stevenson are Co-Chairs of the Atlantic Health Quality and Patient Safety Collaborative. The Collaborative11/28/2018 4:03:00 PM299
Patient Safety Power Play: It’s a Season to Celebrate3347311/20/2018 5:55:05 PMPatient Safety Power Plays Normally, I would wait until December to celebrate the season in my message to you. With the holidays coming up and the weather getting colder, it makes sense to share warm thoughts of family and home in the last month of the year. However, the Canadian Patient Safety Institute family has so much to celebrate this month that I couldn’t resist sharing it with you a little early! I hope you will agree… Firstly, I would like to thank and congratulate everyone who was involved in this year’s Canadian Patient Safety Week (CPSW). As you will see in this month’s article, we had terrific response from across the country and around the world. I believe that we had a great deal of success in spreading the word that Not All Meds Get Along and encouraging conversations about medication safety between patients and their healthcare providers. I was especially proud of the members of Patients for Patient Safety Canada, whom I joined in Ottawa to wish them luck in their meetings with MPs and Senators. There were so many CPSW activities, both those planned by our CPSI team and those held across the country, that I couldn’t begin to list them all! Please read more about this year’s campaign here and offer your own congratulations to everyone involved. Our successes during Canadian Patient Safety Week are a vital part of all the exceptional work we have accomplished in the past month. Not only did we hold the first meeting of the eighteen-month Measuring and Monitoring for Safety project, but we also held another TeamSTEPPS Master Trainer session with our partners at Alberta Health Services. I am delighted with the progress of these two projects, since they both lend support to our mission of inspiring and advancing a culture committed to sustained improvement for safer healthcare. Finally, I wanted to share one more success with you, on behalf of CPSI. We were invited by Health Canada to host a town hall session in Halifax for the Advisory Council on the Implementation of National Pharmacare. With over 80 residents from Nova Scotia and the Maritimes in attendance, patients, caregivers, academics, students and providers had their voices heard on pharmacare. Several speakers mentioned the importance of medication safety and the need for improved information for patients, medication reconciliation, polypharmacy and the value of a national surveillance system. CPSI has already provided a submission to the Council and we will be forwarding a synopsis of this event to Health Canada. As you can see, I am deeply proud of the progress we are making on our new strategy – Patient Safety Right Now – and I invite you to share your own stories about how you and your organization are working to make Canada’s healthcare system the safest in the world! In fact, you can help us today by signing a petition we sponsored help support Health Canada’s labelling guidelines for non-prescription medication and natural supplements. In less than five minutes, you can help ensure clear labels for products that can pose a risk for Canadians and help us achieve our goal of patient safety… right now! Questions? Comments? My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 11/20/2018 7:00:00 AMNormally, I would wait until December to celebrate the season in my message to you. With the holidays coming up and the weather getting colder, it11/20/2018 6:04:41 PM149

 Latest Alerts



Echoes of Past Disasters3357637031/1/2018 7:00:00 AMMedicationCalifornia Hospital Patient Safety OrganizationThis alert addresses patient safety incidents that result when a chemotherapy medication is given by the wrong route. Wrong medication errors for intrathecal chemotherapy fortunately are rare, but, when they occur, can have severe consequences. The alert provides three cases of wrong route administration or near misses. The alert identifies several challenges associated with intrathecal chemotherapy and highlights the need to learn from near miss events.11/26/2018 10:59:34 PM
Data Snapshot: Complications Linked to Iatrogenic Enteral Feeding Tube Misplacements33601369912/1/2017 7:00:00 AMDevicePennsylvania Patient Safety Authority (USA)This alert discusses the patient safety incidents related to misplacement of feeding tubes. The Pennsylvania Patient Safety Reporting System database identified 166 enteral feeding tube misplacements that occurred over a six-year period between January 1, 2011, and December 31, 2016. Development of a pneumothorax was the most common outcome of iatrogenic enteral feeding tube misplacement for patients 60 through 89 years old. Complications of other misplacements included coiling during placement, perforation, and placement in the wrong portion of the gastrointestinal tract. More than half of the events (56.0%) were reported as Serious Events, including two deaths. Almost half of the misplacements were discovered with a chest x-ray study, which is one of the recommended practices for verification.11/26/2018 10:59:38 PM
Warming Blankets and Patient Harm33603369812/1/2017 7:00:00 AMDevicePennsylvania Patient Safety Authority (USA)This alert discusses patient safety incidents related to use of warming blankets. The Pennsylvania Patient Safety Reporting System identified 278 events occurring in July 2004 through August 2017 resulting in harm or potential harm to patients associated with the use of warming blankets. Of these, 11 events (4%) were reported as Serious Events resulting in harm up to and including death. Preliminary review of all events revealed thermal injury to be the most frequently reported patient harm (36%; n = 100). Examples of patient harm or potential harm identified in event reports include hyperthermia, hypothermia, skin tears, and/or irritation from adhesives, and equipment problems. The alert provides risk reduction strategies to prevent similar incidents.11/26/2018 10:59:39 PM
Medication Errors in Outpatient Hematology and Oncology Clinics33612369712/1/2017 7:00:00 AMMedicationPennsylvania Patient Safety Authority (USA)This alert discusses the various types of medication errors that occur in outpatient hematology and oncology clinics. A query of the Pennsylvania Patient Safety Reporting System database for reports from July 2015 through June 2017 in outpatient hematology and oncology clinics affiliated with hospitals or health systems revealed 1,015 reported medication errors. Analysts sought to characterize the types of medication-error events that occurred in this practice setting, identify contributing factors, and describe appropriate system-based risk reduction strategies. More than half (53.7%) of the errors reached the patient. The most commonly reported event types included dose omissions (15.3%) and wrong dose/over dosage (13.1%). High-alert medications were reported in 55.5% of the events. The most commonly prescribed high-alert drug class was antineoplastic agents (94.3%), followed by opioid analgesics (2.3%), and anticoagulants (1.4%). Fluorouracil, CARBOplatin, and PACLitaxel were the three most commonly reported antineoplastic agents. Overall, antineoplastic agents, colony stimulating factors (e.g., pegfilgrastim), and systemic corticosteriods (e.g., dexamethasone) were the most common medication classes involved in medication-error events. Due to the potential hazards associated with antineoplastic agents, special care is warranted to reduce the risk of errors associated with this class of medications. Error reduction strategies in outpatient hematology and oncology clinics begin with a risk assessment of medication use processes and focus on patient information, order communication, quality processes, and risk management. The alert provides several risk reduction strategies.11/26/2018 10:59:40 PM
Preparing for Unplanned Admissions to the NICU 33640369612/1/2017 7:00:00 AMNeonatal/PaediatricPennsylvania Patient Safety Authority (USA)This alert discusses the patient safety issues related to both premature and term infants who required unplanned admission to the neonatal intensive care unite (NICU). An unplanned admission to the NICU may happen because of unexpected maternal, fetal, delivery, or post-delivery conditions. In the United States, the number of admissions to the NICU continues to rise, with most infants presenting as preterm, with a low birth weight or with a clinical condition requiring specialized care. The Pennsylvania Patient Safety Reporting System data was analyzed at five-year intervals (2006, 2011, and 2016) and included 3,385 reports related to unplanned admissions to the NICU. Of these reports, 95.5% were submitted as incidents that resulted in no patient harm. The alert provides factors that can place an infant at increased risk of admission to the NICU; the factors are categorized into maternal conditions (e.g. diabetes), delivery conditions (e.g. C-section), and fetal conditions (e.g. low birth weight). The most frequently reported conditions related to an unplanned admission to the NICU were respiratory distress (29.5%), metabolic issues such as hypoglycemia and hyperbilirubinemia (16.2%), prematurity (9.5%), neonatal abstinence syndrome (NAS; 7.6%), and infection (6.1%). Each of these conditions is expanded on further with information on risk factors and treatment. 11/26/2018 10:59:45 PM