|Lessons from a Coroner's case||14436||16||2/1/2012 7:00:00 AM||Care Management||Australia||Victoria Department of Health (Australia)||This alert describes a fatal patient safety incident where failure to diagnose a small bowel obstruction resulted in death. An elderly patient presented to the emergency department (ED) with abdominal pain and diarrhoea. The patient was treated conservatively by a junior doctor as abdominal X-ray showed no evidence of obstruction. The patient re-presented two days later with a similar problem and was again treated conservatively by a junior doctor. Subsequently, the patient complained of feeling unwell at home and collapsed on the way to hospital. Upon arrival at ED the patient had no heartbeat and resuscitation was unsuccessful. The cause of death was not apparent and the case was reported to the Coroner.
The Coroner’s investigation found that death was caused by a small bowel obstruction. The Coroner commented that a review of medical management indicated that management was reasonable and appropriate. However, contributing factors were the following:
- the absence of specific guidelines for managing abdominal pain in the elderly in ED, and
- lack of escalation to more senior staff.
The alert also referenced the Victorian Clinical Governance Policy Framework 2008 which provides a guide on clinical care governance for health service boards, chief executive offi cers, managers and clinicians, who are all ultimately accountable for the provision of safe quality health care. References for overview of abdominal pain in elderly patients and tools for recognizing and responding to clinical deterioration requiring escalation in care are provided.||7/7/2015 8:47:46 AM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||General Patient Safety;Patient Safety Incident|
|Amiodarone maintenance was infused at 210ml/hr instead of 21ml/hr||14601||178||4/1/2012 6:00:00 AM||Medication||Hong Kong||Hong Kong Hospital Authority||This alert describes a patient safety incident where a patient received a wrong dose of a high alert drug due to an error in programming an infusion pump. A patient who was in shock and tachycardia was given a loading dose of IV Amiodarone 150mg in 100mL D5, to be followed by a maintenance dose of 600mg in 500mL D5 over 24 hours (at 21mL/hour). However, the maintenance infusion was completed in 3 hours and it was found that the infusion rate was wrongly set at 210mL/hour instead of 21mL/hour.
Contributing factors included:
1. Mistook the presence of a decimal point before the “0” on rate display (ie. 21.0 versus 210 mL/hour).
2. Lack of independent double-checking of pump settings before commencing the infusion.
3. No regular monitoring of infused amount / volume after commencement.
Recommendations to prevent similar patient safety incidents are provided.||7/7/2015 9:17:43 AM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Medication Safety;Medication Incident;Patient Safety Incident|
|Distractions in the Operating Room||14798||3226||6/1/2014 6:00:00 AM||Surgery||United States of America||Pennsylvania Patient Safety Authority (USA)||This alert discusses the patient safety incidents that can occur in the operating room due to distractions and/or interruptions related to human communication, equipment such as surgical alarms or technology (e.g. phone calls, pagers).
Distraction is a threat to patient safety in the operating room (OR). Analysis of events reported through the Pennsylvania Patient Safety Reporting System from January 2010 through May 2013 revealed 304 reports of events occurring in the OR in which distractions and/or interruptions were indicated as contributing factors. Attention is warranted to all events impacted by distraction in the OR regardless of frequency, due to their high potential to result in serious patient harm. Distraction is particularly detrimental to performance of complex tasks that require higher levels of cognitive processing, such as those frequently encountered in the OR.
With regard to case-irrelevant communications (CICs), defined as communication not relevant to the surgical procedure in progress. Half of all CICs consisted of “small talk.” Although surgeons initiated and received the greatest number of CICs, visitors to the OR (defined as external staff not belonging to the OR team involved in the current surgical procedure) initiated CICs with the highest levels of observable distraction (i.e., causing team members to pause, disrupting workflow). Communications directed to nurses and anesthesia providers resulted in higher levels of distraction than communications directed to surgeons.
Distraction from computers and personal electronic devices (PEDs) is also a growing concern for OR teams. The widespread use of computers in clinical settings, along with the recent rapid growth in the use of cell phones and smartphones, has contributed to a heightened focus on the potential for error and harm caused by distractions that result from the use of these devices, particularly within the OR environment. “Distracted doctoring” is a term coined by the media to describe this phenomenon. Distraction from smartphones and other mobile devices was identified as one of the top 10 health technology hazards for 2013 by ECRI Institute.
The following are examples of Serious Events (i.e., events involving patient harm) reported and
associated with distraction in the OR:
—— Wrong-side surgery
—— Wrong-site surgery
—— Transfusion of the wrong blood to the wrong patient
—— Failure to remove a piece of resected bowel, requiring a return to the OR
—— Injection of a patient using an unlabeled syringe and needle previously used on another patient
—— Failure to notice a significant loss of evoked potential from a patient’s arm during spinal surgery
—— Inflation of a tourniquet applied to a patient’s leg for longer than intended, resulting in neurovascular changes
Studies examining the impact of distraction in the OR setting, along with guidelines and tools developed by perioperative professional associations and patient safety agencies to limit and/or ameliorate the negative impact of distraction are discussed (e.g., application of the “sterile cockpit” concept from aviation, reducing distractions from technology and noise, use of surgical safety checklists and briefings, teamwork training). Engagement of surgeons and multidisciplinary teams is necessary to address the problem of distractions in the OR.||7/22/2015 5:51:59 PM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist|
|Support to minimise the risk of distress and death from inappropriate doses of naloxone||15076||3426||10/26/2015 6:00:00 AM||Medication||United Kingdom||NHS Commissioning Board||This alert addresses the need for appropriate use of naloxone in opioid overdose. Previously a Stage One: Warning Alert was issued drawing attention to the safety implications of inappropriate doses of the opioid/opiate antagonist naloxone. While naloxone use can be life-saving in respiratory depression and respiratory arrest, the previous Stage One Alert highlighted that use of naloxone in patients where it is not indicated, or in larger than recommended doses, can cause a rapid reversal of the physiological effects for pain control, leading to intense pain and distress, and an increase in sympathetic nervous stimulation and cytokine release precipitating an acute withdrawal syndrome. Hypertension, cardiac arrhythmias, pulmonary edema and cardiac arrest may result from inappropriate doses of naloxone being used for these types of patients.
This Stage Two: Resource Alert points to the resources that have been developed in response to the Stage One Alert to support all providers of NHS funded care to ensure local protocols and training related to use of naloxone reflect best practice.
Key resources include:
• UK Medicines Information (UKMI) considered the relevant literature base and consulted with a range of national stakeholders to a unique comprehensive review to be used to inform actions to minimise the risk of excessively high doses of naloxone and inform appropriate dosing in all settings and circumstances when naloxone is indicated http://www. evidence.nhs.uk/search?q=%22What+naloxone+doses+should+be+ used+in+adults+to+reverse+urgently+the+effects+of+opioids+or+opiates%22.
• The working group updating the 2007 Drug misuse and dependence – UK guidelines on clinical management has published preliminary advice on naloxone before addressing its supply and use more fully in the published update planned for 2016 http://www.nta.nhs.uk/uploads/chairsletter-naloxone- 22july2015.pdf. The advice covers naloxone dosing in overdose situations, take-home naloxone products that can be supplied and training that should be provided, now and following legislation to make naloxone more widely available from October 2015 onwards.
• NHS England has provided supporting information and shares local learning and local resources via its network of Medication Safety Officers http://www. england.nhs.uk/wp-content/uploads/2015/02/psa-naloxone-supp-info.pdf.
Recommendation are provided for all organizations providing NHS funded care where naloxone is prescribed, dispensed and/or administered. ||5/31/2017 7:22:15 PM||6||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Improving Medication Safety;Medication Incident|
|Error Related to Lithium Dosage Conversion||15102||3401||4/1/2015 6:00:00 AM||Medication||Canada||Manitoba Health||This alert describes a patient safety incident of drug overdose related to dose conversion of milligrams and mmol/mL of lithium carbonate, a drug with a narrow therapeutic index.
A personal care home resident had been taking lithium carbonate (150mg capsule) twice daily for many years for bipolar disorder. After finding an elevated serum lithium level, a reduction in the lithium dose was required. Lithium carbonate is not available in a lower solid dosage form. As a result, lithium citrate syrup was dispensed to meet the prescribed dose. The resident received a medication dose that was 38 times the amount prescribed. The resident required transfer to the Intensive Care Unit for dialysis due to toxic levels of lithium. The resident recovered and was transferred back to the personal care home.
The contributing factors included the following:
• The discrepancy between the units ordered (mg) and the units supplied (mmol/mL) required a dose conversion. This conversion did not occur when dispensed by the pharmacy.
• There were no maximum dose warnings generated by the pharmacy software.
• The dose had been calculated at the pharmacy and printed on a label. The label had been affixed to the outside of the liium citrate bottle concealing information on the bottle.
• Lithium ctrate is not considered to be a “High Alert” medication; independent double checks were not required.
• The lthium ctrate bottle supplied was 500 mL. With the dose prescribed, there would be 217 doses in one bottle. Therefore, when the larger dose was dispensed at the time of medication administration, it was not noted to be a large amount taken from the bottle.
Recommendations to prevent similar patient safety incidents of overdose related to dose conversion between two different units of measure are provided.||5/31/2017 7:22:53 PM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Improving Medication Safety;Medication Incident|
|Development of a Pressure Ulcer in a Hospitalized Patient ||15133||3525||10/1/2016 6:00:00 AM||Care Management||Canada||Manitoba Health||This alert describes a patient safety incident of development of a pressure ulcer related to patient transfer and incomplete communication of existing orders. The incident is described.
A patient was admitted to hospital with respiratory distress. While admitted and being treated for respiratory concerns, the patient also underwent debridement to an existing pressure ulcer. Debridement had not been previously recommended by the patient’s consulting plastic surgeon. Following the debridement, the patient’s wound was graded as a Stage 4 pressure ulcer.
A contributing factor was described. The recommendation from the consulting plastic surgeon not to debride the wound was
communicated to the receiving hospital at a previous patient admission six months prior, but was not reflected on the transfer referral form sent to the admitting hospital at this admission.
System learnings are provided in the alert.||5/11/2020 2:18:24 AM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Echoes of Past Disasters||15185||3703||1/1/2018 7:00:00 AM||Medication||United States of America||California Hospital Patient Safety Organization||This 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 PM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Data Snapshot: Complications Linked to Iatrogenic Enteral Feeding Tube Misplacements||15189||3699||12/1/2017 7:00:00 AM||Medical Device||United States of America||Pennsylvania 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.||5/11/2020 2:18:34 AM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Warming Blankets and Patient Harm||15190||3698||12/1/2017 7:00:00 AM||Medical Device||United States of America||Pennsylvania 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.||5/11/2020 2:18:35 AM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Medication Errors in Outpatient Hematology and Oncology Clinics||15191||3697||12/1/2017 7:00:00 AM||Medication||United States of America||Pennsylvania 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.||2/11/2019 10:53:52 PM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|