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Pressure Ulcer1763434149/1/2015 6:00:00 AMCare ManagementCanadaManitoba 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.5/11/2020 2:18:11 AMulcère de pression, ulcère de décubitus, échelle Braden, formation du personnel 6https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseGeneral Patient Safety;Patient Safety Incident
Pressure Ulcer1763734119/1/2015 6:00:00 AMCare ManagementCanadaManitoba HealthThis 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.5/11/2020 2:18:12 AMulcère de pression, ulcère de décubitus, prévention des ulcères de pression, soins des https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseGeneral Patient Safety;Patient Safety Incident
Improper operation of pressure ulcer prevention mattresses and pillows48833409110/22/2009 6:00:00 AMPressure UlcerDenmarkThis alert discusses the potential patient safety incidents of pressure ulcers developing when pressure ulcer prevention mattresses and pillows are used incorrectly. Two incidents are described, one of a hospitalized patient and one home care client. Strong pressure on the skin as a result of incorrect or lack of pressure relief can – even after a short time – lead to the client or patient developing pressure ulcers. In addition, adverse events of this type can cause healing to be delayed and existing pressure ulcers to worsen. The alert provides recommendations on the appropriate use of mattresses and seat cushions.2/14/2022 7:47:59 PMpressure ulcer prevention mattress, pressure ulcer prevention pillows, seat cushions alternée, régulation d’air, volume d’air, coccyx, ulcères de décubitus, plaies de lit https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Development of a Pressure Ulcer in a Hospitalized Patient1763234169/1/2015 6:00:00 AMCare ManagementCanadaManitoba HealthThis 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.5/11/2020 2:18:11 AMpressure 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.aspxFalseGeneral Patient Safety;Patient Safety Incident
A delay in care for a patient with a Stage II Pressure Ulcer led to its progression to Stage IV1711314610/1/2010 6:00:00 AMCare ManagementUnited States of AmericaNew 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.5/11/2020 2:16:07 AMdélai dans les soins, cotes de risques de plaies de pression, escarre de décubitus https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseHealthcare Associated Infections;Patient Safety Incident
Hospital-Acquired Pressure Ulcers Remain a Top Concern for Hospitals1757634673/1/2015 7:00:00 AMCare ManagementUnited States of AmericaPennsylvania 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. 5/11/2020 2:18:06 AMescarre de décubitus, plaie de lit, dressage, blessure des tissus profonds, impossibles à https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseGeneral Patient Safety;Patient Safety Incident
Stage 3-4 Pressure Injuries in Long Term Care Residents1796337686/1/2017 6:00:00 AMCare ManagementCanadaManitoba HealthThis alert briefly discusses the development of pressure ulcers in four long term care residents. Contributing factors identify non-compliance with the wound care policy and procedure, suboptimal interdisciplinary communication, and inadequate documentation of the wound prevention and care plan. Recommendations to prevent similar incidents are provided.5/11/2020 2:19:14 AMulcère de pression, ulcère de décubitus, soins des plaies, prévention des plaies, manque 4https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Retained Instruments / Material -- Dressing Material1820639677/1/2020 6:00:00 AMPressure UlcerHong KongHong Kong Hospital AuthorityThis alert describes a patient safety incident of retention of a foreign body related to wound care, documentation and continuity of care. A patient had been receiving sacral sore care by the Community Nursing Service (CNS) since December 2017. The patient’s wound outlet was getting smaller with deep tunnels and increased amount of exudate. Hydrofera blue foam was used for packing and was changed daily with a 3 cm tail fixed on the buttock skin. In January 2020, the patient was admitted due to worsening wound condition. The wound packing information could not be retrieved upon admission. The foam was not noted or removed during sacral wound dressing. Patient was discharged home and wound care by CNS resumed. In March 2020, the patient was readmitted as there was no improvement. During wound irrigation, a piece of 7 cm Hydrofera blue foam was flushed out from wound and was compatible with the one packed in January 2020. 11/30/2021 10:02:29 PMsoins communautaires, soins à domicile, soins de courte sacrée, plaie de lit, ulcère de décubitus, plaie de pression, plaie de décubitus, exsudat, orifice de sortie de la plaie https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Prevention Strategy - Progressive pressure ulcer171651961/10/2010 7:00:00 AMCare ManagementUnited States of AmericaNew 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.5/11/2020 2:16:13 AMplaie de pression, escarre de décubitus, soins des plaies https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseHealthcare Associated Infections;Patient Safety Incident
Adult Pressure Ulcer Protocols Not Designed for Children1772837042/1/2016 7:00:00 AMCare ManagementUnited States of AmericaOregon 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.5/11/2020 2:18:33 AMulcères de décubitus, enfants, ensemble de mesures de prévention https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse