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Pressure Injury17954377610/1/2017 6:00:00 AMCare ManagementCanadaManitoba HealthThis alert identifies a patient safety incident of development of a stage 3 pressure injury in a long term care resident. Contributing factors included only partial implementation of the Pressure Injury Prevention and Treatment guideline for wound care management. Recommendations included routine multidisciplinary safety huddles for patients/residents assessed to be at risk for the development of a pressure injury.5/11/2020 2:19:12 AMulcère de décubitus, ulcère de pression, plaie de lit, prévention des plaies de pression, soins des plaies
Pressure Injury17935379310/1/2018 6:00:00 AMCare ManagementCanadaManitoba HealthThis alert briefly discusses a patient safety incident of development of a stage three pressure injury to the right buttock of a patient. Contributing factors identified inadequate communication of the presence of a stage two pressure ulcer at the time of transfer to another facility. This increased the possibility that the wound would progress to a stage three pressure injury. Recommendations to prevent similar incidents are provided.5/11/2020 2:19:10 AMulcère de décubitus, plaie de lit, plaie de pression de stade trois, transfert, transfert du patient, l’échelle de Braden, soins des plaies
Pressure Injury Prevention Protocols Essential in all Care Settings for all Populations18036389011/14/2018 7:00:00 AMCare ManagementUnited States of AmericaOregon Patient Safety Commission (USA)This alert discusses the incidence of pressure injuries in outpatient settings, in the emergent care area and in pediatric populations. Prevalence of pressure injuries tend to be associated with inpatient settings (e.g., hospitals and long-term care facilities). This is reflected in the available clinical practice guidelines on pressure injury prevention which are primarily for inpatient settings. However, patients in outpatient settings are also susceptible to pressure injury. Pressure injuries are common in the Emergency Department (ED), even for a short stay. Factors such as a patient’s age, presence of a serious medical illness, and limited mobility can contribute to a patient’s risk. Additionally, the length of stay for most ED patients (99.2%) in the United States is over two hours. Much of the time a patient is in the ED is spent on a gurney, which may not be recommended for extended use. A surgery that takes more time than expected can increase a patient’s risk for pressure injury. 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 pressure injury prevention for neonates and children. The alert provides several recommendations to prevent the likelihood of pressure injuries in outpatients, the emergent care area and in the pediatric population.7/23/2020 3:11:21 AMgurney, pressure relieving mattress civière, matelas de soulagement de la pression soins de blessure, ulcère de décubitus, maladie médicale, long séjour, mobilité limitée, durée de
Increase in Pressure Injuries Reported in 2020: What We Are Learning1813340333/9/2021 7:00:00 AMPressure UlcerUnited States of AmericaOregon Patient Safety Commission (USA)This alert addresses the increase in pressure injuries submitted in 2020. Pressure injuries accounted for 12% of 2020 hospital reports, including two reports related to COVID-19 patients in prone position. Common themes among the causes identified by hospital reporters during their adverse event investigations were found: • Documentation or communication issues • Missed or incomplete inspections or assessments • Complex patient comorbidities The alert provides a number of resources to support organizations in their strategies to prevent pressure injuries and a recommendation to address this adverse event.12/1/2021 2:39:51 PMsoins de courte durée, soins de longue durée, soins palliatifs, soins de réadaptation, établissement de soins palliatifs, soins infirmiers, soins des plaies
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 de communication, communication interdisciplinaire 4
Healthcare Acquired Pressure Ulcers (HAPU)17292ML01012/1/2009 7:00:00 AMCare ManagementUnited States of AmericaMaryland Office of Healthcare Quality (USA)"The Clinical Alert describes the impact of Healthcare Acquired Pressure Ulcers (HAPU) on patients and their care. The Office of Health Care Quality (OHCQ) believes that the number of Level 1 HAPU reportable events (any Stage III or IV pressure ulcer or deep tissue injury acquired in a hospital setting) are under reported in Maryland. The alert summarizes the experience of one Maryland teaching hospital that closely monitored their HAPU and began reporting their findings to the OHCQ. A summary of patient characteristics, root causes, and corrective actions is provided. "5/11/2020 2:12:19 AMStage 3 or 4 pressure ulcers acquired after admission to a healthcare facility Plaie de pression de gravité 3 ou 4 survenant après l'admission Événements liés à la gestion des soins 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 dresser, soins des plaies, inspection de la peau, évaluation des risques, acquis dans la Patient Safety;Patient Safety Incident
Managing risks during the transition period to new ISO connectors for medical devices1762634213/27/2015 6:00:00 AMMedical DeviceUnited KingdomNHS Commissioning BoardThis alert addresses the potential for patient safety incidents when using various medical devices and a variety of connectors or adapters resulting in a misconnection and wrong route errors. The source of the alert provides information on introduction of new enteral feed administrations fitted with new connectors and describes how the phased in implementation will proceed. Risks during the transition period are also described. The alert identifies that different types of medical devices can easily be connected using Luer connectors. For example, an inflation tube of a blood pressure monitor can be connected to an intravenous catheter; an enteral feed administration set can be connected to a tracheostomy tube. In the UK and worldwide, such wrong route errors have resulted in patient injury and death. To reduce the risk of misconnections, the International Organization for Standardisation (ISO) has developed a series of new International Standards for small bore connectors in a range of medical devices (ISO 80369). The standards define the design of the connectors for these applications so that the risk of misconnections with other connectors in the series is reduced. Recommended action items are identified for all organizations impacted by this change.5/11/2020 2:18:09 AMconnector, inflation tube, blood pressure monitor, intravenous catheter, tracheostomy tube jeu d'administration d'alimentation entérale, raccord Luer, tube de gonflage, moniteur de Patient Safety;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
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