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Preventing infant death and injury during delivery46377JC147/1/2004 6:00:00 AMCare ManagementThe Joint Commission (USA)"The overall goal for labour and delivery units is for a healthy and safe birth for the mother and infant. However, there have been patient safety incidents reported where tragedy occurs and the newborn dies. Contributing factors related to perinatal mortality include absence of early and regular prenatal care for the mother, maternal age, previous cesarean section, diabetes, substance abuse, non-reassuring fetal status, placental abruption, ruptured uterus, and breech presentation. This Sentinel Event Alert provides information about identified root causes as well as actions to reduce risk in perinatal mortality."7/7/2015 8:47:40 AM6
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
Express Levothyroxine Doses in Micrograms not Milligrams213437253/8/2017 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert focuses on the expression of medication strength and the error-prone process of converting between different units of measure. Multiple cases of errors and near misses involving levothyroxine dose conversions from milligrams (mg) to micrograms (mcg) and vice versa have been reported. Canadian manufacturer labels express levothyroxine doses in micrograms (mcg) only. However, throughout the medication-use process (e.g., prescribing, dispensing, and administration), levothyroxine doses may be expressed in micrograms (mcg) or in milligrams (mg). As a result, patients and healthcare providers may need to convert doses from milligrams (mg) to micrograms (mcg), or vice versa, to match the prescribed dose to a particular product. Errors in the calculations required to convert between units are contributing to these errors and near misses. A common calculation error occurs when converting between 0.025 mg and 25 mcg, causing in a 10-fold error in dosing. The resultant dose, sometimes 250 mcg rather than 25 mcg, is considered a reasonable dose for some patients and, as such, does not raise a red flag for most practitioners. A recommendation to prevent dose conversion errors is provided. 9/17/2019 4:01:11 PM6
Pressure Ulcer4702934149/1/2015 6:00:00 AMPressure UlcerManitoba HealthThis alert addresses the patient safety incidents of development of pressure ulcers by clients after admission to a health care facility. A review of multiple incidents found that the limitations of the Braden Scale and the lack of guidance to direct staff to the appropriate interventions increased the likelihood the pressure ulcer would progress to stage 3 or 4. A recommendation to mitigate recurrence of similar incidents is provided.5/31/2017 7:22:37 PM6
Blood Transfusion Events—Lessons Learned from a Complex Process6975036699/1/2016 6:00:00 AMBlood Products/TransfusionPennsylvania Patient Safety Authority (USA)This alert discusses the patient safety incidents of blood transfusion events, provides international research regarding incidents and approaches to improve the safety of blood transfusions and provides strategies to reduce risk of patient safety incidents. From January 1, 2010, through December 31, 2014, healthcare facilities reported 19,687 events involving a blood transfusion to the Pennsylvania Patient Safety Authority. Of these reports, 19,492 (99%) were categorized as Incidents that did not result in patient harm. A majority of the events (16,513) were reported under the category of transfusions. Only 0.99% were reported as Serious Events, resulting in patient harm. Of the 10 events associated with severe harm or death, only 1 event was attributed to the patient receiving the wrong blood. Transfusion events occurred most frequently in patients age 70 to 79 years, followed by age 60 to 69, and age 80 to 89. The most frequently reported event type was transfusion event (83.88%) followed by an error related to procedure/treatment/test (6.66%) and complication related to a procedure/treatment/test (4.36%). Transfusion is not without serious risk, ranging from mild reactions to life-threatening conditions. Transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and hemolytic transfusion reactions (HTR) represent the most common morbidity and mortality events reported nationally. Hemovigilance surveillance programs, emerging both internationally and in the Unites States, seek to learn from both Serious Events and Incidents, to continually improve the safety of blood transfusions. Advances in donor screening; improved testing of the blood supply; use of emerging technology, such as barcoding; and improvements in transfusion medicine practices have been found to increase the safety of blood transfusion.2/11/2019 10:55:26 PM6
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