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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 Patient Safety;Patient Safety Incident
Elderly resident with a pressure ulcer recieves care in several facilities18846WRHA0522/1/2011 7:00:00 AMClinical Administration/DocumentationCanadaWinnipeg Regional Health Authority (Canada)This safety alert discusses a fatal patient safety incident that occurred as a result of ineffective patient handover between several health care facilities. An elderly personal care home (PCH) resident was transferred to a community hospital with nausea, vomiting and constipation for further assessment of a possible bowel obstruction. A CT of the abdomen revealed a mechanical distal small bowel obstruction. The patient was transferred to another facility for surgery and returned to the PCH approximately one week later. Upon return to the PCH, staff noted bruising to the extremities and several areas of skin breakdown in the form of blisters on the thighs and buttocks. As well, within the week, staff noted that the resident’s surgical area was not healing well and had become infected. Antibiotics were ordered and administered. Several days later, the resident was transferred to a community hospital following episodes of coffee ground emesis and loose bowel movements and subsequently transferred again to the facility where the previous surgery had been performed. Later that month, the resident passed away.7/7/2015 8:59:49 AMsoins de longue durée, soins de courte durée transfert inter-établissement du patient, transfert intra-établissement du patient, transition des soins, communication, évaluation de 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 AMplaie de pression, plaie de lit, communication, système d'information, déclenchement automatique, données de laboratoire, délai dans les soins, cotes de risques de plaies de Associated Infections;Patient Safety Incident
Latex: A Lingering and Lurking Safety Risk1805738693/1/2018 7:00:00 AMCare ManagementUnited States of AmericaPennsylvania Patient Safety Authority (USA)This alert discusses the on-going patient safety incidents of exposure to latex products by patients with a known latex allergy. Pennsylvania healthcare facilities reported 616 latex-related events that occurred from 2014 through 2016, including 72 near miss events. Analysis revealed that latex indwelling urinary catheters were the most common source of inadvertent exposure in patients with documented latex allergies (75.0%, n = 408 of 544). Latex products that come in contact with mucous membranes (e.g., urinary catheters) cause more severe reactions than those that contact the skin (e.g., gloves), which makes the predominance of reports involving indwelling urinary catheters even more concerning. The perioperative care area accounted for the highest number of both exposures and near misses (57.1%, n = 352 of 616). Event narratives highlight contributing factors such as deficits in communication, documentation, supply management, and staff awareness. Strategies to address these contributing factors may include screening, thoughtful handoffs, evaluation of product alternatives, assessment of staff awareness, and observation of practice patterns. The majority of exposure events (98.7%, n = 537 of 544) were reported as Incidents (i.e., an event that could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services). Seven events were reported as Serious Events, all with a harm score of E (i.e., an event that occurred that contributed to or resulted in temporary harm and required treatment or intervention). Thirty-six unique medical products were described in the 544 exposure events. Indwelling urinary catheters were the most common source of latex exposure described in event narratives (75%), followed by gloves, Penrose drains, and red rubber catheters. The top 3 strategies to prevent patient exposures were staff recognition that the patient had no latex allergy wristband, staff identification of the allergy during a preoperative interview, and staff recognition that a latex allergy was undocumented. The alert provides discussion of contributing factors and risk reduction strategies.11/4/2021 2:36:42 PMcatheterization, phlebotomy, production pressure, workflow, distractions, door signs neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium
Risk of Mix-ups between Ephedrine and Epinephrine16947ISMPC405/1/2007 6:00:00 AMMedicationCanadaInstitute for Safe Medication Practices Canada"As a vasoconstrictor, epinephrine is 100 to 1,000 times more potent than ephedrine. Mix-ups between these two drugs have resulted in serious patient harm. The bulletin highlights a report received by ISMP Canada involving a critical incident with a mix-up between ephedrine and epinephrine as well as references several other major errors with these medications. The drug names look alike and this problem is compounded by the fact that both names start with the letter "e" and the drugs are therefore likely to be stored in close proximity in medication storage areas. The products may also be similarly packaged in 1 ml ampoules. A Canadian hospital reported that a patient in labour inadvertently received 1.3mg intravenous (IV) of epinephrine instead of 5 mg IV of ephedrine. The nurse had taken a telephone order for the ephedrine when the patient's blood pressure remained low after initiation of an epidural anesthesia. The nurse was in the process of inadvertently infusing 5 mg of epinephrine but the injection was stopped due to the patient's sudden severe hypertension, tachycardia and nausea. Both the mother and infant were discharged home several days later. Cardiology follow up indicated that the mother had probably experienced a subendocardial myocardial infarction. "7/7/2015 9:21:32 AM"Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation Safety;Medication Incident;Patient Safety Incident
Autonomic Dysreflexia18182NSW4411/1/2010 6:00:00 AMCare ManagementAustraliaNew South Wales Department of Health (Australia)"Patients with spinal cord injury at or above the sixth thoracic (T6) level can be susceptible to autonomic dysreflexia, a potentially life-threatening medical emergency. Autonomic dysreflexia is a sudden and severe rise in blood pressure resulting from an isolated event triggered from a nociciceptive stimulus that can result in intracranial heaemorrhage, fits, arrhythmias, hypertensive encephalopathy and even death. Common causes of autonomic dysreflexia are listed with primary causes related to bladder and bowel distension, pressure sores or multiple other causes. This Safety Notice provides detailed information for health care professionals ranging from Emergency Medical Services, Emergency Departments to Staff in general hospitals and wards to be aware of the causes and treatments of autonomic dysreflexia. Area Health Services suggest that health care professionals review local practices to include the suggested actions and to ensure an autonomic dysreflexia management algorithm is available in each health service. Actions to reduce risk have been included as well as a treatment algorithm for spinal cord patients who develop autonomic dysreflexia and hypertensive crisis."7/7/2015 8:58:35 AMÉvénements liés à la gestion des soins "lésion de la moelle épinière, pression artérielle, ambulance, algorithme de traitement Patient Safety;Patient Safety Incident
Skin Integrity Issues Associated with Pulse Oximetry18338PA1206/1/2005 6:00:00 AMCare ManagementUnited States of AmericaPennsylvania Patient Safety Authority (USA)"Since the 1980's, pulse oximeters have been used for patient care, to estimate the oxygen saturations of arterial blood. Since the pulse oximeters are non-invasive, convenient to use and often portable, their used has expanded to a variety of settings including during patient transport in an ambulance, spot-checking on general medical-surgical units and outpatient areas/centres, during sleep studies, while exercising testing, home monitoring of infants at risk for sudden infant death syndrome or patients receiving respiratory therapy treatments and even in dental offices during anesthesia. However, patient safety incident reports have indicated that patients have sustained both minor and serious injuries that range from cuts/lacerations, skin discoloration, blanched pressure areas/necrosis, indurations, burns and even to blisters, during patient care and observation. This Patient Safety Advisory provides information about how these injuries have occurred as well as actions to reduce risk. "7/7/2015 8:58:36 AM"services médicaux d'urgence, transport, patient hospitalisé, patient externe, soins à domicile, respiratoire, anesthésiologie, dentaire Événements liés à la gestion des soins Patient Safety;Patient Safety Incident
Sterile Water Should Not be Given “Freely”18343PA1256/1/2008 6:00:00 AMMedicationUnited States of AmericaPennsylvania Patient Safety Authority (USA)"This Patient Safety Advisory discusses serious and fatal patient safety incidents that can occur with the use of sterile water for injection and sterile water for inhalation (high alert drugs). Several patient incidents are described and recommendations to reduce risk of occurrence are provided. Contributing factors to the incidents include the following: - failure among healthcare practitioners to recognize the danger of infusing plain sterile water intravenously to treat hypernatremia, - bags of sterile water for injection and inhalation are being mistaken for intravenous (IV) solutions when they are stocked on patient care units, - hospital materials management departments may inappropriately provide patient care areas with liter bags of sterile water, - emergency malignant hyperthermia boxes found in the operating room and postanesthesia care unit can be another source of sterile water bags. These boxes often are stocked with 1 L bags of sterile water to dilute dantrolene sodium for injection, used to treat malignant hyperthermia. Unused or partially used bags of the solution may find their way into IV stock or be hung as an IV solution during emergent treatment. - Respiratory therapy staff may also store or bring bags of sterile water to patient care units for humidification devices used with ventilators or continuous positive airway pressure (CPAP) devices. - sterile water for inhalation is available in 250 mL, 500 mL, 1 L, 2 L, and 3 L bags that can be used for wet setups. Some of these bags not only look similar to other IV solutions, but they can also be attached to IV tubing (and may be listed for purchase as “IV solutions”)."7/7/2015 9:22:40 AM"Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation Safety;Medication Incident;Patient Safety Incident
Problems with infusions and sampling from arterial lines18892NPSA0507/28/2008 6:00:00 AMMedicationEngland and WalesNational Health Service Commissioning Board (England and Wales)This Rapid Response Report addresses patient safety incidents that can occur with use of arterial lines. Patient safety incidents include the wrong infusion fluid being delivered through the arterial line, a faulty sampling technique such as sampling blood glucose from lines with glucose running (and patient treated based on falsely high readings) and mis-selecting potassium chloride instead of sodium chloride 0.9% for injection. Contributing factors include look-alike labelling and packaging of intravenous infusion bags and inadequate checking before attachment. A particular risk is the need to cover the infusion with a pressure bag which obscures the label during use. Risks of confusion are increased when patients are transferred from other areas. Sampling errors include problems when taking and managing the samples, contamination by inadequate flushing and confusing arterial with venous lines. Actions to reduce risk are provided.7/7/2015 9:22:42 AMchlorure de potassium pour injection, chlorure de sodium 0,9 % pour injection potassium chloride for injection, sodium chloride 0.9% for injection Safety;Medication Incident;Patient Safety Incident
Pressure ulcers17452328511/1/2014 6:00:00 AMCare ManagementCanadaManitoba HealthA patient with peripheral vascular disease had Buck’s traction applied following the diagnosis of a fractured hip for pain control and fracture stabilization. When the traction was removed 26 hours later, reddened, circular, bruised areas were found in area covered by the traction boot. Despite treatment of the areas, pressure ulcers developed. Amputation of the foot was needed approximately three months later. The patient experienced intense pain before and after the application of the traction. The skin covered by the traction boot was not assessed following the application of the traction until the time of surgery.5/11/2020 2:17:08 AM Associated Infections;Patient Safety Incident