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Q. What is an alert or an advisory?

A. An alert or advisory is a piece of information that has been produced and publicly posted that outlines a specific type of patient safety incident or series of incidents that did occur or could have occurred.  These alerts typically tell the story of what happened and what an organization learned - how to mitigate risk, and prevent reoccurrence of similar incidents.

Q. What is a recommendation?

A. A recommendation is an action or series of actions that should be taken to reduce, manage or control any future harm, or probability of harm, associated with an incident. (Adapted from the WHO definition of “action to reduce risk” in the January 2009 Conceptual Framework for the International Classification for Patient Safety – Technical Report.

The recommendations in Global Patient Safety Alerts are grouped in five categories that we have adapted from the Veteran’s Administration National Center for Patient Safety Triage and Triggering Questions and are related to human factors engineering:

Communication: issues related to communication, flow of information, and availability of information as needed. These recommendations reveal the importance of communication when using equipment, the application of policy and procedure, unintended barriers to effective communication, and an organization's culture with regard to sharing information.

Training: issues related to routine job training, special training, and continuing education; including the timing of that training. Training recommendations may concern application of approved procedures, correct use of equipment, or appropriate manipulation of protective barriers. They also focus on the interfaces between people, workspace, and equipment.

Fatigue/Scheduling: the influence of stress and fatigue that may result from change, scheduling and staffing issues, sleep deprivation, or environmental distractions such as noise.

Environment/Equipment: factors related to use and location of equipment; fire protection and disaster drills; codes, specifications and regulations; the general suitability of the environment; and the possibility of recovery after an error has occurred.

Rules/Policies/Procedures: related to the existence and ready accessibility of directives including technical information for assessing risk, mechanisms for feedback on key processes, effective interventions developed after previous events, compliance with national policies, the usefulness of and incentives for compliance with codes, standards, and regulations. The qualifications of the facility and employees for the level of care provided; orientation and training for compliance with safety and security measures including handling of hazardous material and emergency preparedness; and the availability of information to all part time, temporary, or voluntary workers and students are also considered.

For information about how to categorize your own recommended actions that arise from an incident analysis please see the Canadian Incident Analysis Framework.

Q. How is the information on Global Patient Safety Alerts organized?

A.  The information within the database is organized in two ways – by alert and by recommendation, which means you are able to find a specific alert or advisory or a specific recommendation or recommendation type.

The alerts are organized and can be filtered according to their primary topic, country of origin and contributing organization.  Within the alert summary record you can find more information such as publication type and if the alert concerns one incident or multiple incidents.  Also, you will find a link to the original and full text alert on the contributing organization’s website.

Recommendations are organized according to their category and the topic of the alert from which they are contained in.  For example, the recommendation: “Assess lighting, including task lighting, in patient care areas to determine if it is adequate for administration of medications. Staff members should have an optimal light source available to support their reading of armbands and information related to medication use (e.g., medication labels, MAR) at the bedside.”  is from the alert Inadvertent Administration of Insulin to a Nondiabetic Patient from ISMP – Canada which is classified under the topic medication.

Q. What is an alert summary?

An alert summary is a synopsis and key elements of a published alert as reviewed by a patient safety expert.  The summary is meant as a tool for users to decide if the full alert will be of interest to them.

Q. What is a topic?

A.  A topic is the primary type of patient safety incident that the alert is concerning.  Expert reviewers have read each alert and categorized them according to 22 topics which may also be used as filters.

Q. How can I browse the alerts and recommendations?

A. Simply click on the “Browse” tab from any page on the website.  From here you can decided if you want to browse our alerts (left hand side) or recommendations (right hand side).  You can browse everything in our database or by topic area.

Q. What are the filters and how will they change my search results?

A. The filter options from your alert search or browse results are:

    • Topic - Topic – what type of patient safety incident the alert is mainly about
    • Country – what is the contributing organization’s country of origin
    • Organization – which contributing organization the alert comes from

The filter options for your recommendation browse or search results are:

    • Topic - Topic – what type of patient safety incident the alert is mainly about
    • Category - The recommendations in Global Patient Safety Alerts are grouped in five categories that we have adapted from the Veteran’s Administration National Center for Patient Safety Triage and Triggering Questions and are related to human factors engineering.  See “What is a recommendation for more information”

Q. I have updates to the information that I have found on Global Patient Safety Alerts or would like to report a broken link.  How can I do this?

A. Please email with your concerns about the information as presented and we will do our best to make sure we have the very best information available.

Q. How can I save my search or an alert for future reference?

A. There are a few ways to save the contents of Global Patient Safety Alerts:

    1. Save the page to your browser bookmarks or favourites
    2. Email the page to yourself or a friend
    3. Print the page to your printer or to a PDF to save for later

Q. How can I contribute to Global Patient Safety Alerts?

A. Your organization can become a contributor by emailing and indicating your interest.

Q. How do you determine which alerts to include?

A.  To be included in GPSA, an alert or advisory must be concerning a patient safety incident which resulted from a human interaction with healthcare.  That is, we have excluded alerts that concern the inherent safety of drugs or devices IE recalls.  To find these alerts, please visit:

The other inclusion criteria is that the alert must be publicly available on a website external to Global Patient Safety Alerts.

Strategies for effective searching and usage of Global Patient Safety Alerts

    1. Be as specific as possible in your search.  Global Patient Safety Alerts will look for your search terms in all text of the alert summaries and recommendations.
    2. Use the filters on the left hand side to narrow the results to what you are looking for.
    3. Try different spellings of terms.
    4. Try both the trade name and the generic name of the product or medication.