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Death Associated with an IV Compounding Error and Management of Care in a Naturopathic Centre9002937331/4/2018 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis Safety Bulletin describes a fatal patient safety incident involving a medication compounding error and inappropriate management of care in a naturopathic centre. A patient was discharged from hospital after surgical excision of a cancerous tumour and was further treated, in a collaborative arrangement, by a conventional medical team and a naturopathic doctor at a complementary care centre (CCC). The naturopathic doctor prescribed a complex tissue- and wound-healing formulation, which included selenium, for twice-weekly IV administration. The selenium solution was prepared by a compounding pharmacy and was added to the formulation on site at the CCC. The patient had received this healing formula on 12 previous occasions, with no reported reactions. However, shortly after initiation of the 13th dose infusion, she became nauseous and diaphoretic. The infusion was stopped, and homeopathic remedies were administered, with no clinical improvement. Over the next several hours, the patient’s condition continued to deteriorate. When the patient began to experience hypotension, shortness of breath to the point of cyanosis, and chest pain, she was transferred to the emergency department of a local hospital, where she later died. Postmortem investigations showed that the selenium concentration in the infusion was 1000 times greater than intended, which likely contributed to the patient’s death. Contributing factors identified included confirmation bias, use of the abbreviation “µg” instead of “mcg” for “micrograms”, and a visual check only for the weighed products instead of using a print out for each weighed product. Recommendations are provided for pharmacies (re: compounding processes), complementary care centre (re: emergency response processes and preparation, storage and administration of admixtures), and regulatory agencies.5/11/2020 3:44:59 AM6https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Packaging and Labelling Are at Root of Many Medication Errors88866CPSO018/1/2010 6:00:00 AMMedicationCalifornia Hospital Patient Safety Organization (USA)"This article addresses how medication packaging and labelling can contribute to medication patient safety incidents. Several examples of packaging and labelling problems are given with diagrams to illustrate the narrative. Actions to reduce risk, based on the UK National Health Service (NHS) guide for labelling and packaging of injectable medications, are provided. "7/7/2015 9:20:31 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Safer ambulatory syringe drivers88869NPSA03112/16/2010 7:00:00 AMMedical DeviceNational Health Service Commissioning Board (England and Wales)This Rapid Response Report discusses potential and actual patient safety incidents that have resulted from over or under infusion of opioids and other palliative care medications, resulting in harm to patients. Use of syringe drivers which have rate settings in millimetres (mm) of syringe plunger travel versus rate settings in millilitres (mL) of fluid to be infused have resulted in errors providing the wrong rate of infusion caused by inaccurate measurement of fluid length or miscalculation or incorrect rate setting of the device. Dose errors also occur because of different models using mm per hour or mm per 24 hours. Other issues include syringes becoming dislodged, inadequate device alarms and lack of internal memory (a technical issue which makes establishing the reason for any over or under-infusion difficult).5/11/2020 2:15:40 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Detecting harm following paracetamol overdose88871NPSA04110/29/2010 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This signal address the need to reduce the risk of harm to patients who have taken an overdose of paracetamol / acetaminophen. Numerous reports of serious or fatal patient safety incidents are referred to; in these the treatment of patients with a paracetamol overdose was delayed or inadequate. Underlying causes of the incidents included: - patient complained of general symptoms such as vomiting and decreased appetite and a paracetamol overdose was not suspected; - patient presented with paracetamol overdose but no plasma paracetamol level had been taken; - blood tests were performed that indicated impending liver failure but no treatment was commenced; - patient received incorrect dose of acetylcysteine following paracetamol overdose. A single patient safety incident is described in detail whereby a patient attended the emergency department following an accidental overdose of paracetamol, had investigations and was discharged home. The patient attended again three days later complaining of pains to lower back and legs. She was seen by medical staff and discharged home. She returned acutely unwell the following day, presented into resus where her condition deteriorated further and she died. Actions to reduce risk of occurrence of these incidents is presented. 7/7/2015 9:21:38 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Extravasation of neonates revisited88872NPSA0452/26/2010 7:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This signal provides good practice and guidance from local trusts to reduce risks of extravasation injury to neonates from intravenous fluid. 7/7/2015 9:21:38 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Overdose of intravenous paracetamol in infants and children88873NPSA04710/29/2010 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This signal address the risk of harm to infants and children from inadvertent overdose of intravenous paracetamol / acetaminophen and provides some actions to reduce risk. One patient safety incident is described whereby the healthcare provider intended to give a dose of paracetamol 10 mg/kg intravenously (IV) but gave 100 mg/kg instead. A doctor was summoned immediately and the overdose was treated. Treatment consisted of HDU (high dependency unit) level monitoring, acetylcysteine (Parvolex®) infusion and monitoring of blood tests. Contributing factors to paracetamol overdoses include: - lack of awareness amongst healthcare professionals of neonatal and paediatric drug dosage regimens; - patients receiving doses of paracetamol in both theatre and ward due to poor documentation; - human error relating to setting up infusion pumps to administer intravenous paracetamol (incorrect rate or incorrect/ no volume to be infused (VTBI)); - confusion between dosing regimens for oral and intravenous paracetamol with clinical staff believing they are interchangeable; - 10 times dose calculation errors in both the prescription and administration of intravenous paracetamol. Brief actions to reduce risk are provided and further guidance can be found on the MHRA Website. 7/7/2015 9:22:43 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Preventing fatalities from medication loading doses88874NPSA04911/25/2010 7:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This Rapid Response Report discusses patient safety incidents that have led to patient harm as a result of incorrect use of loading doses and/or subsequent maintenance regimens. The fatal and severe harm patient safety incidents that have occurred between 2005 and 2010 in the UK were as a result of incorrect doses, omitted or delayed administration or unintentional continuation of higher doses. Actions to reduce risk are provided.7/7/2015 9:22:43 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Reducing harm from omitted and delayed medicines in hospital88875NPSA0542/24/2010 7:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This Rapid Response Report outlines a recommended staged approach to the reduction of harm from omitted or delayed critical medicines once a patient is admitted to the hospital. This is a particular concern for patients with chronic conditions such as Parkinson's Disease or those with sepsis or pulmonary embolisms. The most common medications involved include anti-infectives (antibiotic and antifungals) and anticoagulants.7/7/2015 9:22:43 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Reducing treatment dose errors with low molecular weight heparins88876NPSA0587/30/2010 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This Rapid Response Report addresses dosing errors that can lead to patient harm through an overdose or underdose. Contributing factors to these type of patient safety incidents include: - not weighing patients prior to dosing, - estimating body weight, - recording body weight inaccurately, - miscalculation of doses based on a patient’s weight, - the prescribed, dispensed or administered dose and frequency of low molecular weight heparins (LMWH) were outside accepted guidelines for the required clinical indication and other predisposing conditions such as renal failure; and - limited patient information (i.e. weight, dosage, indication and intended duration of treatment) communicated at transfers of care. Actions to prevent risk of occurrence are provided.7/7/2015 9:22:44 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Safer administration of insulin88877NPSA0636/16/2010 6:00:00 AMMedicationNational Health Service Commissioning Board (England and Wales)This Rapid Response Report discusses patient safety incidents associated with the use of insulin, frequently resulting in administering the wrong dose. Factors contributing to these incidents include the following: - the inappropriate use of non-insulin (IV) syringes, which are marked in mL and not in insulin units, - the use of abbreviations such as ‘U’ or ‘IU’ for units. When abbreviations are added to the intended dose, the dose may be misread, e.g. 10U is read as 100, and - insufficient training in the use of insulin by healthcare professionals. Actions to reduce risk of occurrence are provided.7/7/2015 9:22:44 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse