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Awareness of the Patient Safety Crisis in Canada6724/23/2019 2:52:28 PMPatient Safety NewsAwareness of the Patient Safety Crisis in Canada THE ISSUES We are facing a patient harm crisis of epidemic proportions. The Canadian public knows almost nothing about it. As soon as they learn, the public urgently prioritizes safer healthcare.Canadians should have an expectation that their healthcare is safe, and in most cases it is.However, every resident of Canada must learn that there are risks in our healthcare system, despite the efforts of thousands of dedicated healthcare providers across Canada. In our healthcare system, there is a death from patient harm every 13 minutes and 14 seconds. It is the third leading cause of death in Canada. One out of 18 hospital visits results in preventable harm. These incidents generate an additional $2.75 billion in healthcare treatment costs every year.This level of harm is simply unacceptable. THE SURVEY In 2018, the Canadian Patient Safety Institute (CPSI) commissioned Ipsos Public Affairs to survey Canadians about their awareness of the rates of patient harm in our healthcare system. We sought a baseline read of Canadians' understanding of patient safety, with the main objectives of Assessing knowledge of patient safety and patient safety incidents in Canada; Understanding how Canadians prioritize patient safety; Determining how Canadians would like to receive information about patient safety, if at all; and, Assessing experience with patient safety incidents. Ipsos Public Affairs surveyed 1003 Canadian adults, weighted by gender, age, region and income. The credibility interval was +/- 3.5%. Ipsos found that while 44% of respondents identified as caregivers at some point in their lives, 30% stated they had a chronic disease or illness themselves. Out of the 199 respondents who identified as parents, 13% said that they have a child with a chronic illness. KEY FINDINGS Canadians show limited knowledge of patient harm. One third of Canadians rank patient safety in their top three healthcare priorities, with just under one in ten ranking it first. About one in ten correctly say that patient safety incidents are the third leading cause of death in Canada. Only one in ten Canadians believe that someone dies from a patient safety incident every 15 minutes in Canada. Six in ten say the $2.75 billion cost of patient safety incidents in Canada is higher than they expected. Despite the limited knowledge of the patient safety crisis in Canada, one in three Canadians has experienced a patient safety incident. One in three Canadians stated that they either personally experienced a patient safety incident (12%) or have a loved one who did (24%). Misdiagnosis, falls, infections and mistakes during treatment are the most common types of patient safety incidents. Those who have experienced a patient safety incident most commonly cite distracted or overworked health care providers as the largest contributing factors that led to the incident. Once informed about the scale of the problem, Canadians demonstrated far more concern about patient harm and wanted more information. Three‐quarters of Canadians are concerned about experiencing a patient safety incident, ranking it in their top three (compared to originally 1 in 3), including 1 in 4 ranking patient safety incidents as their top priority. Three in four Canadians are interested in learning how to keep safe in healthcare, Eighty per cent say they'd like to receive this information delivered via (in order of preference) healthcare provider; print, digital and in-person. This knowledge should be provided in real time (when patients go to the hospital for surgery and upon a new diagnosis of a serious health problem), but some also believe it should be general knowledge. CONCLUSIONS We are facing a patient harm crisis of epidemic proportions. The Canadian public knows almost nothing about it. As soon as they learn, the public urgently prioritizes safer healthcare. Canadians should have an expectation that their healthcare is safe, and in most cases it is. Every resident of Canada must learn that there are risks in our healthcare system, despite the efforts of thousands of dedicated healthcare providers across Canada.Healthcare providers, healthcare systems, and the Canadian Patient Safety Institute must empower residents of Canada with information and tools to ask good questions, connect with the right people, and learn as much as they can to keep them or a family member safe while receiving healthcare. Patient experience in the healthcare system should be characterized by clear, honest, two-way communication.WHAT CAN YOU DO?Ask us about patient experiences of harm in Canada's healthcare system. We invite you to read some of the stories shared by members of Patients for Patient Safety Canada, and the changes they have championed in our healthcare system to keep patients safer.Ask us what you can do to keep yourself and your loved ones safe in the healthcare system. The Canadian Patient Safety Institute designs and collects resources designed to help patients navigate the healthcare system by asking questions and being informed. Five Questions to Ask About Your Medications Tips and Tools for Talking to your Healthcare Team Tips to identify Deteriorating Patient Condition Shift to Safety tools and resource to keep you safe Share what you have learned. We have discovered that, as soon as we learn about the scale of the public healthcare crisis, we become far more concerned. Post your experiences on social media and use the hashtag #PatientSafetyRightNow – with your help, we will inform anyone who uses our healthcare system about the crisis and teach them how to keep themselves and their loved ones safe.ABOUT USThe Canadian Patient Safety Institute (CPSI) is the only national organization solely dedicated to reducing preventable harm, improving the safety of the healthcare system, and engaging patients and families as partners in safe care. Patients for Patient Safety Canada (PFPSC) is the patient-led program of CPSI and the Canadian arm of the World Health Organization's PFPS program. As patient partners, these volunteer members harmed by healthcare contribute to patient safety improvements at all system levels. CPSI and PFPSC are committed to working together with the public, patients, healthcare providers, and healthcare leaders to make Canadian healthcare safer. BACKGROUND INFORMATION 2018 Ipsos Patient Safety Survey Risk Analytica 2017 The Case for Investing in Patient Safety in Canada Ipsos 2016 National Health Leadership Conference Survey Canadian Patient Engagement Guide 4/23/2019 3:00:00 PMAwareness of the Patient Safety Crisis in Canada THE ISSUES: We are facing a patient harm crisis of epidemic proportions. The Canadian4/23/2019 5:26:05 PM52
#SuperSHIFTER - Encourage conversations between patients and providers: 5 Questions to Ask About Your Medications114/10/2019 7:15:15 PMSuper SHIFTERS SuperSHIFTERS Alice Watt, Medication Safety Specialist at the Institute for Safe Medication Practices Canada (ISMP Canada) and Mike Cass, Senior Project Manager at the Canadian Patient Safety Institute, were instrumental in the development and widespread dissemination of the 5 Questions to Ask About Your Medications. The 5 Questions creates a platform for patient engagement and promotes safe medication practices. What are the 5 Questions to Ask About Your Medications? The 5 Questions are a launching pad to encourage conversations between patients and healthcare providers. Patient Advocate Jill Adophe has been quoted as saying, "Patients want a dialogue, not a monologue. They want a choice and a voice." The 5 Questions tool gives patients something to think about in preparing for these conversations. ​ ​ ​ Alice Watt ​ Mike Cass How did you land on these particular questions for the 5 Questions tool? In 2014, a Medication Safety Summit concluded that a checklist would engage patients in medication safety. ISMP Canada was asked by the Canadian Patient Safety Institute to lead this opportunity, working with patients and a number of patient safety and medication specialists. Co-designed with representatives from Patients for Patient Safety Canada (PFPSC), the working group took a collaborative approach, ensuring that the patient voice guided the questions. An initial environmental scan of medication safety literature and tools produced questions for consideration. Safety tools reviewed included medication reconciliation materials that had been developed following analyses of medication incidents at transitions of care (and shared with the Canadian Medication Incident Reporting and Prevention System). Those questions were narrowed down to create the final 5 Questions that would resonate most with the target audience. What we ended up with went beyond our expectations! What do patients and providers have to say about the 5 Questions? In a recent Canadian Patient Safety Week survey, 63 per cent of healthcare providers said that patients are asking more questions about their medications, and 60 per cent of patients said they are asking more questions about their medications. Healthcare providers say they are distributing the 5 Questions to patients, posting them in examination rooms and clinics, and using the tool as a guide for conversations between patients and providers. What is being done to spread the use of the 5 Questions? We conducted several surveys with patients and healthcare providers to validate the 5 Questions and people told us to make it available in multiple languages. This has been another fascinating element of the project. Today, the 5 Questions tool is available in 25 languages from Albanian to Korean and Ukrainian. Organizations are still asking us to make the 5 Questions available in more languages and we're working on that! Another feature of the 5 Questions is that healthcare organizations can add their logo to the tool, and it has been customized by more than 200 organizations to date. More than five million patients are learning about the 5 Questions through an eye-catching digital poster campaign in doctors' offices and hospital waiting rooms in Ontario, Alberta, British Columbia and Quebec. The 5 Questions tool has also been shared with organizations in other sectors through initiatives like the Home Care Collaborative and the Medications Safety at Transitions of Care Safety Improvement Project. Were there any surprises or key learnings that you can share in developing the 5 Questions? The enthusiasm of patients to promote the 5 Questions in their communities has been so rewarding. They have asked for copies and distributed them locally in grassroots efforts. There has been interest from sectors outside of acute care, including long term care, home care, primary care, and the 5 Questions have proven useful at transitions of care. We've been delighted by the international interest in the tool and the fact that it's now available in so many languages around the world. We know that working with patients and having them participate in the co-design was crucial and will continue to be important as we develop new tools. There's always room for modification, but as they were created, the 5 Questions have become a successful platform for starting a conversation. We tapped into an unmet need and the pick-up has snowballed. Have you expanded on the initial 5 Questions tool? A new 5 Questions handout has been developed with the Canadian Deprescribing Network and Choosing Wisely Canada, with the goal of reducing the use of opioids for pain after surgery. Key messages in the handout focus on safe storage and disposal of opioids. We are now looking at developing a 5 Questions tool to address the use of opioids for short-term pain and dental pain. Where can our readers go for a copy of the 5 Questions, or learn more? Click on the link to download the 5 Questions to Ask About Your Medications poster. For more information, contact or 4/11/2019 6:00:00 AMSuperSHIFTERS Alice Watt, Medication Safety Specialist at the Institute for Safe Medication Practices Canada (ISMP Canada) and Mike Cass, Senior4/10/2019 7:38:04 PM396
Patient Safety Power Play: April comes in like a lion!8494/5/2019 7:05:52 PMPatient Safety Power Plays My favourite quote about Spring is that March comes in like a lion but goes out like a lamb. However, since we are north of the 49th parallel, we know the old saying applies more accurately to April. With the number of projects and initiatives on the go at CPSI, we are certainly coming in to April like a lion – though we have no intention of going out like a lamb! First, I would like to announce the upcoming STOP! Clean Your Hands Day on May 6. Our national part in the World Heath Organization's global SAVE LIVES Clean Your Hands campaign recognizes the importance of hand hygiene in stopping healthcare-acquired infections. Cleaning our hands is the easiest way to prevent the spread of infection. Our theme this year is Clean Care Conversations, and we are developing tips and tools everyone can use to start discussions about hand hygiene. You can register for updates here to be notified when new tools or activities are announced. Next, I want to recognize the work that we are doing through our Policy, Legal and Regulatory Affairs (PLRA) Advisory Committee. Made up of healthcare and regulatory members from across Canada, the group met to provide guidance for CPSI on next steps to influence legislation and policy related to mandatory incident reporting in Canada. They offered feedback on the newest draft of CPSI's Policy Influence Framework, consulted on the Canadian Quality and Patient Safety Framework, and provided strategic advice on CPSI's broad and increasing involvement in new and emerging policy issues. Our next in-person advisory committee meeting is planned for this fall, and I promise to keep you updated. We held another important meeting recently, the first ever for the Federal, Provincial, and Territorial Government Patient Safety Network. This network, comprised of Health Canada members and Assistant Deputy Ministers from provinces and territories across Canada, met to share their common priorities and to align priorities around patient safety in their jurisdictions. Several themes emerged from the discussion, including each jurisdiction's desire to Learn about other jurisdictions' policies and legislation; Focus on not only patient safety but also health care provider safety; Create a transparent and just culture; Learn about reporting, learning and sharing data from adverse events; Improve patient and public engagement; Thread cultural safety throughout policies; and Acknowledge the impact of the social determinants of health. The enthusiasm from the group to keep collaborating is just what we need to help meet CPSI's goals of strengthening commitment. Finally, I have to offer my most sincere congratulations to the Safety Improvement Project teams who have spent the first few months of the year promoting our brand new 18-month learning collaboratives. Thanks to their diligent efforts and the overwhelming response from healthcare organizations across the country, all three will begin this month with full enrolment! I invite you to share news online about STOP! Clean Your Hands Day, our successful outreach efforts, and if your group is participating in the upcoming learning collaboratives. Please use the hashtag #PatientSafetyRightNow in any social media you share. If you have a story about preventable patient harm, please share it with your audiences through social media – and use the hashtag. Questions? Comments? My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 4/5/2019 7:00:00 PMMy favourite quote about Spring is that March comes in like a lion but goes out like a lamb. However, since we are north of the 49 th parallel, we4/5/2019 7:24:09 PM243
#SHIFTtalks - Reducing abuse and neglect with BCPSLS re:act8464/4/2019 7:21:36 PMSHIFT Talks The British Columbia Patient Safety & Learning System (BCPSLS) has developed an online tool to assist regional health authorities in identifying cases, supporting investigations, and tracking outcomes of adult abuse, neglect, and self-neglect. BCPSLS is the web-based system used by healthcare professionals across BC to report and learn from adverse events, near misses, and hazards. Its mission is to make healthcare safer by fostering a culture of safety, shared learning, and continuous system improvement. Left to right Tammy Simpson (Provincial Coordinator, BCPSLS), Amanda Brown (Director, ReAct Adult Protection Program, VCH) and Sherry Lin (Analyst/Assistant, ReAct Adult Protection Program, VCH) The online tool used to support vulnerable adults is called BCPSLS react. It was first launched in 2011 as a partnership between BCPSLS and Vancouver Coastal Health (VCH) to support VCH's ReAct Adult Protection Program. In 2017 the tool was revised, streamlined, and made available to regional health authorities across the province. So, what have we learned so far? First, we've learned that BCPSLS react is a leading practice in Canada. In 2018, the Canadian Patient Safety Institute, HealthCareCAN, and Health Standards Organization, with support from Patients for Patient Safety Canada, awarded BCPSLS react a Leading Practice within their Excellence in Patient Engagement for Patient Safety recognition program. Second, we've learned that the type of adult abuse and neglect most frequently reported is self-neglect. Signs of self-neglect can include poor personal hygiene, a home environment in disarray, multiple interactions with ambulance services within a short period of time, or an unexpected change in a client's ability to self-manage a chronic condition such as diabetes. A client in this situation may require additional supports such as a revised care plan, further monitoring, or admission to hospital. Another big issue facing BC's vulnerable adult population is financial mismanagement. Although it's not identified as frequently as self-neglect, it can have an enormous impact. In addition to financial losses, it can affect the adult's access to basic necessities, use of healthcare resources, and individual freedom and rights to decision-making when an assessment is needed to determine the adult's incapability. But the most important thing we've learned about BCPSLS react is the positive difference it can make in people's lives. Use of the tool encourages healthcare professionals to put on their "adult guardianship hats", become familiar with identifying cases, and take action to help people who are suffering. One example of this took place last year at an emergency department in BC. A clinician noticed signs of abuse and immediately connected with a designated responder. The designated responder was able to review records in BCPSLS react and identify a long-standing abusive situation. Investigators were then able to complete their investigation and protect the adult from further abuse. Without a resource like react, this patient may not have received the support they needed. According to Susan Barr, Specialist, Vulnerable and Incapable Adults at Island Health, if people receive interventions early, they can stay safe and require fewer services down the road. "Adult guardianship is a holistic view of a patient," explains Susan. "Rather than focusing solely on an ailment, such as a broken hip, it helps identify other supports for patients who have difficulty getting help for themselves. When designated responders become involved, a different lens is applied that can help prioritize patient needs and inform discharge planning." One of the most valuable aspects of BCPSLS react is its ability to capture reports from all levels of healthcare in one secure repository. Records remain centrally located while they are accessed, reviewed, and updated by designated responders across programs and facilities. In addition, users can upload documentation, such as care plans, that can be shared and updated by investigators as needed. Meghan McMenamie is the Site Leader, Social Work, for Mount Saint Joseph and Holy Family hospitals within Providence Health Care (PHC). She believes BCPSLS react is particularly important for PHC because it facilitates communication between its hospital-based services and the community. "React provides a forum for us to pass information back and forth with the community," explains Meghan. "For our high-risk adult protection cases, it's hugely beneficial for us to be able to tag our partners within community services so the patients and their information don't get lost." BCPSLS react also helps provide clients with dignity and person-centred care, as designated responders are able to engage appropriate programs across the continuum to ensure that care providers are on the same page. "Continuity and consistency are so important," adds Meghan. "Healthcare is at its weakest at transitions, so anything we can do to mitigate risk helps us to provide better care to our patients." As use of BCPSLS react spreads through the province, it's exciting to see how health authorities in BC are using the tool to support their adult protection programs. Congratulations, again, to everyone who has helped make BCPSLS react a success in supporting vulnerable adults! 4/4/2019 6:00:00 AMThe British Columbia Patient Safety & Learning System (BCPSLS) has developed an online tool to assist regional health authorities in identifying4/4/2019 7:28:40 PM548
Patients for Patient Safety Canada recognized as world leader in patient engagement647134/2/2019 5:33:58 PMPatient Safety News ​The World Health Organization (WHO) made patient engagement a priority in 2005 by creating the Patients for Patient Safety (PFPS) Programme and launching a global network of PFPS Champions committed to the vision and pledge for partnership described in the London Declaration "to make care as safe as possible as soon as possible". Patients for Patient Safety Canada (PFPSC) is the patient-led program of the Canadian Patient Safety Institute and the Canadian arm of the WHO PFPS network. Since 2006, PFPSC members have partnered in hundreds of patient safety initiatives across Canada at international, national, provincial and local levels. Sharon Nettleton, one of PFPSC's founding members and a past Co-Chair of the volunteer network, has seen great changes in patient engagement making care safer since PFPSC was formed more than a decade ago. "Our impact is seen here in Canada and around the world too," says Sharon. "Many things we first envisioned when PFPSC began have come true – we've played a major role in developing and improving policies and practices, and in education and communication by bringing our perspectives and experiences forward. We've changed hearts and minds by role modeling patient engagement and demonstrating how successfully it can work. Instead of being seen as 'individuals driven by anger or grief', we are now viewed as 'needed partners' who want to be part of 'needed improvements.' Our work empowers us to continue and also encourages others to engage and contribute as patient partners." In April 2017, the Canadian Patient Safety Institute was designated as a WHO Collaborating Centre for Patient Safety and Patient Engagement. To date, the Canadian Patient Safety Institute is the only Collaborating Centre in the world to receive the patient engagement designation. "Patients for Patient Safety Canada is a valued contributor to decisions and actions of the WHO PFPS Advisory Group and are regularly called upon to present at high level meetings and to varied audiences," says Dr. Neelam Dhingra-Kumar, WHO's Coordinator for Patient Safety and Risk Management. "PFPSC members have shared their experiences and mentored similar programs in Ireland, Malaysia, Australia and Mexico. As volunteers, they generously contribute their expertise, playing an instrumental role in shaping the global PFPS Programme and community." In February 2019, the WHO's PFPS Advisory Group invited the Canadian Patient Safety Institute to help guide the global effort to enhance patient and family engagement for the provision of safer health care. Attendees acknowledged the extraordinary success of the Canadian Patient Safety Institute and PFPSC partnership in Canada, considering it an exemplary model that should be replicated in other countries. Attendees at the February 2019 WHO expert consultation meeting. Left to right Dr. Neelam Dhingra-Kumar (WHO), Ioana Popescu (CPSI), Sir Liam Donaldson (WHO), Katthyana Aparicio (WHO), and Sandi Kossey (CPSI) At the meeting, the group discussed the recent WHO Executive Board Global Action on Patient Safety resolution (February 1, 2019) which urges member countries to recognize patient safety as a key priority. It recommends several actions to improve safety, including engaging patients/patient groups as partners. The WHO Director General was asked to submit a progress report on the status of implementation of this resolution in 2021; therefore, this resolution presents an extraordinary opportunity for the WHO PFPS program and global community. "Patient safety is a critical element and the foundation for delivering quality health care," says Sir Liam Donaldson, WHO Envoy for Patient Safety. "The input from the Canadian Patient Safety Institute and PFPSC, as key international experts, will aid in defining a new global vision, strategic directions, and priority interventions and deliverables at international, national and local levels. Over the last 15 years the PFPS Programme achieved much of what we imagined, and, in this journey, we confirmed that we need to partner with patients for patient safety now more than ever." In Canada, PFPSC regularly reviews and revises its goals and priorities to ensure they advance safe care. The group is confident their current priorities are well aligned with the recommendations in the 2019 WHO resolution. These include medication safety, engaging the public and elected officials in advancing safe care, and partnering with other patient groups to advance common patient safety goals. "Over the last decade, PFPSC has progressed from being asked to share their experiences, to now increasingly being asked to contribute as full members of committees, boards, faculty and teams. It has been a real culture shift to help improve safety," says Linda Hughes, PFPSC Co-Chair. "We have championed not only our patient safety cause but also how to effectively engage and empower patients. We have developed a very credible and influential community of patient and family partners across Canada. We are committed to the long-term journey ahead where patients and families are seen as true partners as common practice in every interaction, every setting, and every health system level." Patients for Patient Safety Canada welcome questions, input and ideas at For more information, visit and https// 4/3/2019 6:00:00 AMThe World Health Organization (WHO) made patient engagement a priority in 2005 by creating the  Patients for Patient Safety (PFPS) Programme4/2/2019 5:45:04 PM442

 Latest Alerts



Bed Alarms-Safe use and configuration4714537194/26/2018 6:00:00 AMDeviceAlberta Health ServicesThis alert addresses a patient safety incident of a fall related to bed alarms which may not function properly. The following points are relevant to the incident of a patient fall:  Bed alarms are an alternative strategy for falls prevention.  Alarms may be permanently integrated into the bed or applied as an external device.  Most alarm sensor/pressure pads have a limited life expectancy.  The process for resetting bed alarms varies from brand to brand.  Each brand of alarm has a unique interface with the call bell system Recommendations to prevent similar incidents are provided. As well, specific actions are provided for staff to reduce the likelihood of falls related to bed alarms which do not funcion properly.2/11/2019 10:53:35 PM3
Vaccine storage and cold chain management7050835402/9/2018 7:00:00 AMMedicationNew South Wales Department of Health (Australia)This alert discusses the importance of maintaining a cold chain with the use and distribution of vaccines. Most vaccines used in Australia are temperature-sensitive substances that must be stored between +2ºC and +8ºC at all times to ensure they work effectively. There may be loss of potency if vaccines have been stored at temperatures outside this range. The alert provides reccommendations on necessary education and policies / procedures to ensure that no vaccines are compromised prior to use.2/11/2019 11:02:04 PM
Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders7039835581/9/2018 7:00:00 AMMedical GasNHS Commissioning BoardThis alert discusses the patient safety incidents that can occur when healthcare staff cannot deliver oxygen from cylinders to patients in a timely manner. The design of oxygen cylinders has changed over recent years. Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire valves must be closed when cylinders are not in use. Cylinders are often carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient. An unintended consequence of these changes is that staff may believe oxygen is flowing when it is not, and/or may be unable to turn the oxygen flow on in an emergency. Over a three year period, over 400 incidents involving incorrect operation of oxygen cylinder controls were reported. Six patients died, although most were already critically ill and may not have survived even if their oxygen supply had been maintained. Five patients had a respiratory and/or a cardiac arrest but were resuscitated, and four became unconscious. Incidents involved portable oxygen cylinders of all sizes on trolleys, wheelchairs, resuscitation trolleys and neonatal resuscitaires, and larger cylinders in hospital areas without piped oxygen. A typical incident was as follows: “Patient arrived on coronary care unit with oxygen saturations of 72%. Oxygen in situ and set to correct rate on the flow dial but unfortunately [the valve] was not opened and the patient was not therefore receiving oxygen. Peri-arrest on arrival, [crash team] called …..condition improved …..registered nurse continued to check cylinder was not running out but failed to notice not turned on as indicator green.” Recommendations to prevent similar incidents are provided.2/11/2019 11:01:28 PM
Echoes of Past Disasters4712537031/1/2018 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.2/11/2019 10:53:48 PM3
Medication Error – Phenytoin 750 mg infusion was given at faster rate than prescription7003436421/1/2018 7:00:00 AMMedicationHong Kong Hospital AuthorityThis alert briefly describes a medication error where phenytoin was administered faster than the recommended infusion rate. A patient was admitted for tonic convulsions and fast AF. A loading dose was prescribed of phenytoin 750 mg followed by an intermittent infusion to be given over 30 minutes using the inpatient medication order entry (IPMOE) system. The infusion was administered over 10 – 15 minutes. The patient developed cardiac arrest and was successfully resuscitated. It was determined that the cardiac arrest may have been related to the patient’s underlying cardiac conditions or the faster infusion rate of phenytoin. A recommendation is provided to mitigate the risk of recurrence of similar events.2/11/2019 10:56:32 PM