|Pressure Ulcer||47029||3414||9/1/2015 6:00:00 AM||Pressure Ulcer||Manitoba Health||This 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 PM||ulcère de pression, ulcère de décubitus, échelle Braden, formation du personnel ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Pressure Ulcer||47032||3411||9/1/2015 6:00:00 AM||Pressure Ulcer||Manitoba Health||This alert addresses the development of pressure ulcers in a number of clients admitted to health care facilities.
In reviewing the incidents, the following contributing factors were found:
• The lack of documentation and gaps in the implementation of interventions to reduce pressure may have increased the likelihood that the pressure ulcers would progress to stage 3 or 4.
• Lack of consistency regarding pressure reduction mattress availability increased the likelihood that the most appropriate mattress may not be implemented in a timely manner and possibly contributed to the development of the pressure ulcers.
• Inconsistent interdisciplinary care plan and inconsistent communication in some of the cases regarding wound care along with the lack of discussion with the patient/family as to the agreed upon goals regarding wound care increased the likelihood that the pressure ulcers would progress to stage 3 or 4.
Several recommendations for improvement are provided to mitigate the likelihood of recurrence of these types of incidents.||5/31/2017 7:22:41 PM||ulcère de pression, ulcère de décubitus, prévention des ulcères de pression, soins des ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Development of a Pressure Ulcer in a Hospitalized Patient||47027||3416||9/1/2015 6:00:00 AM||Pressure Ulcer||Manitoba Health||This alert describes a patient safety incident of development of a pressure ulcer with subsequent systemic infection in a hospitalized patient.
The specific incident is described. A patient was admitted to hospital with pneumonia. At the time of admission, there was no documentation of a baseline skin integrity assessment. Four days later, a pressure ulcer was found on their buttocks. Despite the application of a foam dressing to the area, skin breakdown worsened. The patient was discharged from hospital with an order for zinc oxide to the ulcer. Nine days later, the patient was re-admitted to hospital with a Stage 4 pressure ulcer to the coccyx and sepsis likely related to the pressure ulcer.
Factors contributing to the incident were as follows:
1. There was no assessment of the patient’s skin at the time of admission.
2. There was a no standardized documentation tool pressure ulcer risk assessment.
3. There was no policy/guidelines that addressed the need for pressure ulcer prevention or skin and wound care.
4. The documentation of the patient’s care was incomplete, lacking sufficient detail.
5. There was a delay in obtaining a pressure reducing sleep surface for the patient.
6. When a transfer of care occurred between physicians, there was no evidence of a verbal report with respect to the patient plan of care.
7. Members of the interdisciplinary team were not consulted when the pressure ulcer was first discovered. As a result, there was a delay in securing a pressure relieving sleep surface for the patient.
Several recommendations to mitigate the likelihood of recurrence of similar incident are provided.||5/31/2017 7:22:33 PM||pressure ulcer reducing sleep surface surface de sommeil réduisant les ulcères de pression Plaie de pression, ulcère de décubitus, intégrité de base de la peau, pansement en mousse ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|A delay in care for a patient with a Stage II Pressure Ulcer led to its progression to Stage IV||46508||146||10/1/2010 6:00:00 AM||Pressure Ulcer||New Jersey Department of Health and Senior Services (USA)||This alert discusses a patient safety incident of delay of care related to communication issues among healthcare providers. A delay in care for a patient with a Stage II Pressure Ulcer led to its progression to Stage IV due to a system communication failure. It was determined that the cause of the incident was related to the lack of appropriate laboratory data and pressure ulcer risk scores in their electronic medical record which would automatically have triggered the dietary and wound care nurse consults as well as identifying the need for specialty equipment needed for off-loading pressure in susceptible skin areas.
Two strategies to prevent similar patient safety incidents are provided.||7/7/2015 9:26:36 AM||délai dans les soins, cotes de risques de plaies de pression, escarre de décubitus ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Hospital-Acquired Pressure Ulcers Remain a Top Concern for Hospitals||46971||3467||3/1/2015 7:00:00 AM||Pressure Ulcer||Pennsylvania Patient Safety Authority (USA)||This alert discusses the continuing challenge of preventing hospital-acquired pressure ulcers and provides evidence-based recommendations for improved quality of care.
Pennsylvania hospitals reported more than 19,000 pressure ulcer events to the Pennsylvania Patient Safety Authority in 2013. Hospital-acquired pressure ulcers (HAPUs) are a recognized patient safety concern and meet the definition of a reportable event under the Pennsylvania Medical Care Availability and Reduction of Error Act. Despite changes to the Centers for Medicare and Medicaid Services’ inpatient prospective payment system in 2008 that established regulatory and financial incentives for hospitals to prevent HAPUs, they remain a frequently reported hospital-acquired condition.
In 2013, Pennsylvania healthcare facilities reported 33,545 events involving impaired skin integrity to the Pennsylvania Patient Safety Authority through its Pennsylvania Patient Safety Reporting System (PA-PSRS). This represents the fifth most frequently reported patient safety event type. The majority of impaired skin integrity events (n = 19,009, 56.7%) were hospital-reported pressure ulcers.
An analysis of pressure ulcers reported through the Pennsylvania Patient Safety Reporting System from 2007 through 2013 suggests the need for improvement in identification of pressure ulcers present on admission; accurate staging of pressure ulcers; and prevention of HAPUs, in particular stage III, suspected deep-tissue injury, and unstageable pressure ulcers. Patient safety and quality agencies, as well as wound care specialty organizations, have established evidence-based best practices in pressure ulcer risk assessment and prevention. This alert provides a list of resources offering best practice recommendations. ||12/19/2016 11:26:37 PM||Avis sur la sécurité des patients escarre de décubitus, plaie de lit, dressage, blessure des tissus profonds, impossibles à ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Retained consumables/instrument Case 1: Cotton wool-like material||46485||124||7/2/2012 6:00:00 AM||Care Management||Hong Kong Hospital Authority||This alert describes a patient safety incident where supplies used in treatment were retained in the patient's body after a procedure. A patient was admitted to Hospital A for debridement of a right thigh pressure ulcer. The operation was uneventful. The patient was discharged and referred to Community Nursing Service of Hospital B for daily dressing. On a home visit by a Community Nurse, a piece of old cotton wool-like substance soaked with wound discharge substance was found and removed. The patient was readmitted to Hospital A for thigh wound management. No other retained wound dressing was found.
Contributing factors included:
1. Individually packed cotton wool ball might be partially retained in the patient’s wound during wound swabbing and cleansing.
2. Lack of guideline on the use and documentation of wound swabbing and cleansing material.
Recommendations to prevent similar patient safety incidents are provided.||7/7/2015 8:47:48 AM||Alerte suite à un événement sentinelle de pression, plaie de lit, escarre de décubitus, opération, soins à domicile, service de ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Retained PICC internal stiffener stylet||46906||3319||7/1/2014 6:00:00 AM||Device||Hong Kong Hospital Authority||This alert describes a patient safety incident of a retained foreign body following an insertion of a central intravenous line.
A patient was managed in an orthopaedic ward for left groin abscess, bilateral ischial decubitus ulcers and infective spondylitis with psoas abscesses. The vascular surgical team was consulted for insertion of a peripherally inserted central catheter (PICC) for a prolonged course of intravenous antibiotic. An unfamiliar brand of PICC was provided to the surgeon performing the procedure. Migration of the PICC was suspected after reviewing a contrast CT scan of the spine which was taken after the procedure to rule out related sepsis. The catheter was then removed and confirmed to be the retained PICC internal stiffener stylet which was to have been removed at the time of insertion. The patient was managed accordingly and eventually discharged home.
A key contributing factor was that the clinical team was unfamiliar with the device which was used infrequently.
Recommendations to prevent similar patient safety incidents are provided.||5/31/2017 7:44:37 PM||peripherally inserted central catheter (PICC),
stylet cathéter central inséré par voie périphérique (CCIP), stylet ligne IV centrale, nouveau dispositif, corps étranger, corps ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Prevention Strategy - Progressive pressure ulcer||46560||196||1/10/2010 7:00:00 AM||Pressure Ulcer||New Jersey Department of Health and Senior Services (USA)||This alert describes a patient safety incident of a pressure ulcer that progressed while the patient was an inpatient. Patient admitted with a Stage II sacral pressure wound progressed to a Stage IV while hospitalized.
The facility's response to prevent future similar patient safety incidents is provided.||7/7/2015 9:26:36 AM||plaie de pression, escarre de décubitus, soins des plaies ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Adult Pressure Ulcer Protocols Not Designed for Children||47123||3704||2/1/2016 7:00:00 AM||Pressure Ulcer||Oregon Patient Safety Commission (USA)||This alert identifies the risk of development of pressure ulcers in pediatrics. Patient safety reports suggest that pediatric patients are vulnerable to a problem traditionally thought to only be an issue for adults: pressure ulcers. Healthcare facilities that care for children may not have specific pressure ulcer prevention programs in place. Given the anatomic and physiologic differences between adults and children, serious concerns arise about the safety, clinical efficacy, and cost-effectiveness of using adult protocols and products for neonates and children. The alert provides recommended actions to prevent pressure ulcers in pediatrics.||2/11/2019 10:53:47 PM||ulcères de décubitus, enfants, ensemble de mesures de prévention ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Prevention Strategy - Pressure ulcer associated with a device||46558||194||6/1/2011 6:00:00 AM||Pressure Ulcer||New Jersey Department of Health and Senior Services (USA)||This alert addresses the development of patient safety incidents of pressure ulcers related to the use of a respiratory device. Patients have developed Stage III and IV Pressure Ulcers associated with a device (such as BiPAP, tracheostomy). Contributing factors to the events were failure to perform a full body assessment, including areas of skin covered with a device.
Strategies to prevent this type of patient safety incident are provided.||7/7/2015 9:26:36 AM||Bilevel positive airway pressure (BiPAP), tracheostomy plaie de lit, escarre de décubitus, respiratoire, trachéotomie, pansements, recouvrements ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|