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Gas Embolism – Air embolism after removal of CVC70274358710/1/2016 6:00:00 AMCare ManagementHong Kong Hospital AuthorityThis alert describes a patient safety incident of creation of an air embolism following removal of a central venous catheter (CVC). A patient had an operation to repair a fracture of right femur. Post operative course was complicated by myocardial infarction and a haemodialysis catheter was inserted into the patient for renal replacement therapy in the Intensive Care Unit (ICU). The patient’s clinical condition subsequently improved and the care team decided to remove the catheter. The CVC was removed while the patient was sitting upright on an armchair. About 10 minutes later, the patient developed an intra-cardiac air embolism requiring resuscitation. The patient’s spontaneous circulation resumed in 4 minutes. The patient’s condition further deteriorated after another episode of myocardial infarction. He succumbed 3 days later. Contributing factors identified included the following: 1. Lack of awareness of the risks of intravascular air embolism associated with CVC removal. 2. The standard practice of catheter removal was not followed. Recommendations are provided for mitigation of the likelihood of similar incidents.2/11/2019 10:57:58 PM3
Risk of death from failure to prioritise home visits in general practice7049635423/30/2016 6:00:00 AMCare ManagementNational Board of HealthThis alert idenitifes the need to have good practice systems in place to triage and prioritize home visits. A fatal patient safety incident is described. As well 11 incidents relating to general practitioner (GP) home visits reported with a degree of harm equivalent to death or severe harm in a recent two year period. Some of the incidents suggested that there were gaps in the process for deciding if a more urgent response was needed. The alert emphasizes that when a request for a home visit is made, it is vital that general practices have a system in place to assess: • whether a home visit is clinically necessary; and • the urgency of need for medical attention. Recommendations to prevent patient safety incidents related to failure to prioritize home visits in general practice are provided.2/11/2019 11:01:39 PM3
Medication Error - Known drug allergy7036635651/1/2016 7:00:00 AMMedicationHong Kong Hospital AuthorityThis alert describes a medication error where a long term care resident / old age home resident received a medication to which they had a documented allergy. An old age home resident was admitted to hospital for a urinary tract infection. The resident’s health identity card was not brought with them for registration and thus the resident was registered as a patient with a pseudo-ID number. From the resident’s record, the patient had a known allergy to penicillin. However, the doctors were not aware of the drug allergy and entered “No Known Drug Allergy” into the Clinical Management System (CMS). Augmentin® (amoxicillin/clavulanic acid) was prescribed via a computerized inpatient medication order entry system (IPMOE) and one dose of Augmentin® was administered to the patient. The patient’s family brought the health identity card to the hospital for registration the next day and the information was entered into the Clinical Management System. When the next dose of Augmentin® was to be administered, a drug alert message popped up from the IPMOE system. The patient did not suffer any allergic reaction from the first dose of Augmentin®. Contributing factors to this incident included the following: - When patients are registered using a pseudo-ID number, staff can access some linked records but the clinical information, including the allergy history, is not automatically transferred. That information becomes available once the patient’s identity has been verified and the records are merged. - The drug allergy card was not prominently displayed in the patient’s record folder. - Allergy checking was missed by the doctors and nurses. Recommendations to prevent similar medication incidents are provided.2/11/2019 11:01:24 PM19
Wrong Site Surgery149637926/1/2018 6:00:00 AMSurgeryManitoba HealthThis alert describes a patient safety incident of wrong site surgery where an additional surgery was performed in addition to that consented. A client consented to surgery for a trigger finger. The surgeon was not in the operating theatre while the team prepped, draped, and anesthetized the patient. The surgeon returned to the operating theatre and began the surgery. The Time Out phase of the Safe Surgical Checklist was not completed prior to the incision. A left carpal tunnel surgery was completed, in addition to the original consented surgery. Contributing factors included an incomplete Time Out phase of the Safe Surgical Checklist and incorrect marking of the surgical site. Recommendations to prevent similar incidents are provided.9/16/2019 8:23:34 PM3
The Safe Practice of Dry Needling in Alberta46840327710/1/2014 6:00:00 AMOtherHealth Quality Council of AlbertaThe Health Quality Council of Alberta conducted a review of clinical practice issues in dry needling related to pneumothorax, the most common serious adverse outcome following dry needling. Pneumothorax can occur during dry needling if a needle enters the lung tissue; therefore it is critical that the practitioner has thorough knowledge of surface anatomy, the underlying structures of the thorax including anatomical anomalies, as well as knowledge about the management of adverse events such as pneumothorax. Dry needling is a broad term referring to a treatment technique using solid filament needles to puncture the skin for therapeutic purposes and includes a range of approaches, such as acupuncture, intramuscular stimulation, or a similar treatment used by numerous healthcare professionals. Approaches differ in their rationale, needling techniques, and training requirements. In Alberta, professions authorized to practice dry needling include physicians, dentists, surgeons, physiotherapists, occupational therapists, chiropractors, nurses, and naturopaths. The review identified issues related to information for patients, continuing competency requirements for dry needling, safety-related topics in dry needling education, and reporting patient-related serious adverse outcomes. 7/7/2015 9:25:06 AM3
Humeral Head Fracture 623380410/1/2018 6:00:00 AMFallsManitoba HealthThis alert discusses a patient safety incident resulting in a humeral head fracture. The resident had a history of right sided weakness and dementia. The absence of a standardized mobility assessment tool increased the risk for incorrect type of mechanical lift used. A sit stand lift was utilized and was not the recommended lift for this client. Correct procedures for safe application of the sling were not utilized; the sling was positioned above the chest level rather than at the trunk level. Inconsistent safety practices when using the mechanical lift increased the risk of harm. The resident remained attached to the sling and mechanical lift and was left unattended on the toilet. Recommendations to prevent similar incidents are provided.9/16/2019 8:23:23 PM
Humeral Head Fracture 1026380310/1/2018 6:00:00 AMCare ManagementManitoba HealthThis alert discusses a patient safety incident resulting in a humeral head fracture. Concerns regarding the resident’s ability to transfer using a sit stand lift were raised after the incident. A regional policy supporting Safe Client Handling was in development. The existing policy was utilized which did not align with current training. This may have contributed to the use of an incorrect mechanical lift for the client’s needs. The resident was cognitively impaired, known to be aggressive and resist care. A behavioral/psychological assessment was not completed. There was a limited number of staff members who had completed the approved regional behavioral/psychological assessment training. Recommendations to prevent similar incidents are provided9/16/2019 8:23:24 PM
Fall Resulting in Fracture1450380210/1/2018 6:00:00 AMFallsManitoba HealthThis alert describes a patient safety incident of a fall related to equipment failure of a bed alarm. A personal care home resident fell, resulting in fractures of the seventh and eighth ribs as well as a fractured right femur. Staff initiated a bed alarm three weeks earlier following a fall. After this fall, the staff discovered that the bed alarm was not functioning and did not alert staff when the resident exited the bed. A review of the incident found that there was a lack of clarity about bed alarms, the indication for use, effectiveness, how to check batteries, when and how often to check alarms, and responsibility for preventative maintenance. Recommendations to prevent similar incidents are provided.9/16/2019 8:23:25 PM
Myomectomy Complications1482379510/1/2018 6:00:00 AMSurgeryManitoba HealthThis alert describes a patient safety incident of circulatory shock resulting from extensive blood loss. A patient with a uterine prolapse was referred to an ambulatory clinic to be fitted for a pessary. On examination, a prolapsed fibroid 10 cm in size was found. The physician advised the patient that a urinary catheter should be inserted until arrangements could be made for the procedure to be completed in the Operating Room the following week. The patient requested that the fibroid removal be done at this time. The physician obtained consent for the procedure. The fibroid was removed in the ambulatory clinic. Cautery was available for use in the event that bleeding resulted. The patient started to bleed following the procedure. The blood loss was extensive enough to result in circulatory shock. The patient was transported to the Operating Room for emergency surgery to control the bleeding. The patient recovered with no long-term effects. Contributing factors identified that there was no diagnostic imaging used to visualize all possible causes of urinary retention and that the emergency response plan was not initiated. Recommendations to prevent similar incidents are provided.9/16/2019 8:23:31 PM
Fall Resulting in Fracture150437916/1/2018 6:00:00 AMFallsManitoba HealthThis alert briefly describes a patient safety incident of a fall by a client who stumbled when rising in the night, resulting in a fractured femur. Contributing factors included lack of night lighting, deactivation of the bed alarm, lack of floor sensor pads and lack of documentation of a previous fall. Recommendations to prevent similar incidents are provided.9/16/2019 8:23:35 PM