|Pressure ulcers under plaster casts||18922||NPSA080||11/27/2009 7:00:00 AM||Care Management||England and Wales||National Health Service Commissioning Board (England and Wales)||Casts are a required treatment when broken bones require settings and good casting techniques and monitoring should prevent complications such as pressure ulcers. Severe pressure ulcers can lead to pain, prolonged hospitalization and substantial morbidity including amputation. This Signal concerns the delayed recognition of pressure ulcers under plaster casts, leading to patient harm and the need to identify patients at risk for developing pressure ulcers. Healthcare staff should be aware of the possibility that patient ulcers may develop under plaster casts. Education should be provided to patients of warning signs and who to contact if complications develop. Patients with significant vascular disease are at an increased risk for the development of pressure ulcers and patients with diabetes or sensory deficits. Key contributing factors related to the development of an ulcer is the amount of padding or poor alignment of the plaster, staff not appropriately assessing the patient after reports of discomfort by the patients , and staff not aware of heightened risk of patients with known vascular disease and multiple sores. Please review the Signal for more information. ||5/11/2020 2:15:38 AM||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Healthcare Associated Infections;Patient Safety Incident|
|Risk of harm following gastric bypass||17064||99||2/28/2012 7:00:00 AM||Care Management||United Kingdom||National Health Service Commissioning Board (England and Wales)||This alert address the potential for harmful patient safety incidents to patients following gastric bypass surgery. A fatal patient safety incident is described where a patient who had undergone gastric bypass surgery died four years later, as a result of a micro-nutrient deficiency, having been lost to necessary follow up:
“The patient developed a micro-nutrient deficiency (a recognised complication of the surgery) which was not immediately diagnosed because of its comparative rarity. The deficiency eventually led to multi-system involvement requiring hospital admission and, in particular, the formation of ulcers and pressure sores. All of these matters, but most particularly the micro-nutrient deficiency, left the patient vulnerable to infection and with a reduced immune response. In consequence she developed an over-whelming and unusually rapid septic shock from a lung infection, leading to her death.”
Although no other incidents have been reported, they may be more common than incident reporting suggests since gastric bypass surgery has become more common place over recent years, and because complications following surgery are possibly under recognised.
Actions to prevent this type of patient safey incident are provided.||7/7/2015 8:47:47 AM||suivi, carence en micronutriments, défaillance de multisystème, ulcères, plaies de pression, infection, choc septique, réponse immunitaire réduite, chirurgie bariatrique, carence ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||General Patient Safety;Patient Safety Incident|
|Retained Gauze/Segment of Equipment||17073||107||1/3/2012 7:00:00 AM||Care Management||Hong Kong||Hong Kong Hospital Authority||This alert describes two patient safety incidents involving retention of wound dressing in a patient during wound care. In the first instance, a patient with a history of multiple pressure ulcers requiring repeated debridement operations was admitted for deteriorating pressure ulcers. The wound was assessed and treated by packing with a large piece of gauze. Daily wound care was provided. Nine days later, the wound was reassessed and it was documented that "no foreign material" was left in the pressure ulcer. The patient was discharged. Subsequently the patient was readmitted twice for treatment of hypotension. Wound packing and irrigation was performed during hospitalization. On the last admission, a piece of old gauze was found in the patient's left hip joint space at the time of wound assessment. The gauze was removed and the wound irrigated. The patient was stable and later discharged.
The second incident involved a patient with a sacral sore who was referred for wound care upon discharge; no wound packing was prescribed. When the patient was re-admitted for debridement of the sacral wound, 2 pieces of dressing material were found and removed from the wound. The patient was discharged and referred for wound care. On a home visit for wound dressing, incomplete documentation of the "In and Out" wound packing material was found.
Contributing factors included:
1. Insufficient documentation of counting and checking of consumables.
2. Failure to detect the retention of wound dressing materials.
3. Lack of unified clinical protocol for management of patients with pressure ulcer at different stages.
4. Ineffective communication between health care teams on wound care method and the materials used.
5. Non-compliance with hospital protocol on the use of whole pieces of dressing material for wound packing.
Recommendations to prevent similar patient safety incidents are provided.||7/7/2015 8:47:47 AM||plaie de pression, débridement, traitements des plaies, nettoyage des plaies, soins des plaies, remplissage des plaies, irrigation des plaies, plaie de lit, plaie au sacrum ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||General Patient Safety;Patient Safety Incident|
|Extra dressing material found in a sacral ulcer||17509||3321||7/1/2014 6:00:00 AM||Care Management||Hong Kong||Hong Kong Hospital Authority||This alert describes a patient safety incident of a retained foreign body following home care of a pressure ulcer.
A patient with diabetes, hypertension and advanced dementia was under the care of Community Nursing Service (CNS) for a sacral pressure ulcer. She was hospitalized for 5 days for poor oral intake during which time the patient's sacral sore was managed with daily wound dressings.
The patient continued to receive wound care by CNS after discharge. Different wound dressing materials were used to pack the wound at different times. On the fourth home visit, it was discovered that an extra piece of dressing, which was not documented in the Clinical Management Sheet, was inside the patient's wound.
It was determined that a lack of clear documentation on the number of wound packing materials packed and removed in the wound after the wound dressing procedure contributed to the incident.
Recommendations to prevent similar patient safety incidents are provided.||5/11/2020 2:17:19 AM||soins des plaies, ulcères de pression, pansement, tamponnement des plaies, traitement des plaies, évaluation des plaies, visite à domicile ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Autonomic Dysreflexia||18182||NSW44||11/1/2010 6:00:00 AM||Care Management||Australia||New 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 AM||Événements liés à la gestion des soins "lésion de la moelle épinière, pression artérielle, ambulance, algorithme de traitement ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||General Patient Safety;Patient Safety Incident|
|Retained Instruments / Material -- Dressing Material||18206||3967||7/1/2020 6:00:00 AM||Pressure Ulcer||Hong Kong||Hong Kong Hospital Authority||This 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 PM||soins communautaires, soins à domicile, soins de courte durée, soins infirmiers, soins des stomies, soins des plaies soins des plaies, plaie sacrée, plaie de lit, ulcère de ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Aggregate review of pressure ulcer incidents ||17456||3281||9/16/2014 6:00:00 AM||Care Management||Canada||Manitoba Health||An aggregate review was completed on six patients that developed Stage 3/4 pressure ulcers after admission to a health care facility. This review involves three acute care sites and two long term care sites.
The absence of an indicator for predicting pressure sore risk, such as the Braden Scale, increased the likelihood that the health care team would not have a meaningful measure of risk that would guide care plan development.
The absence of a Safe Client Handling and Injury Prevention Program (SCHIPP) increased the likelihood that best practices would not be implemented with regards to turning an repositioning clients and this may have increased the likelihood that there would be skin breakdown.
The lack of readily accessible pressure reduction and redistribution equipment increased the likelihood that the
most appropriate equipment may not be implemented in a timely manner.
The absence of a plan of care that integrates the Braden Scale for predicting pressure sore risk and the Bates -Jensen Wound Assessment Tool (measure of the severity of the ulcer) increased the likelihood that the pressure ulcer would progress to Stage 3/4.
The uncertainty about what interventions are appropriate, what resources are available and what wound care products were indicated complicated the decision making for health care providers and increased the likelihood that prevention and treatment strategies would not be fully implemented.||5/11/2020 2:17:09 AM||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Healthcare Associated Infections;Patient Safety Incident|