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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, évaluation des risques d’ulcère de pression 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 AMpressure reduction mattress ulcère de pression, ulcère de décubitus, prévention des ulcères de pression, soins des plaies, soins de la peau, évaluations de la peau, consultations https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseGeneral Patient Safety;Patient Safety Incident
Prevention Strategy - Pressure Ulcer17619NJ138/1/2010 6:00:00 AMCare ManagementUnited States of AmericaNew Jersey Department of Health and Senior Services (USA)"While hospitalized, a patient developed a Stage III sacral pressure ulcer. It was noted that Inconsistent documentation regarding the stage and description of the ulcer, led to its progression. This short prevention strategy for pressure ulcers includes the development for a pocket assessment guide for all nursing staff. "5/11/2020 2:12:22 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 https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseHealthcare Associated Infections;Patient Safety Incident
Prevention Strategy - Pressure Ulcer17630NJ144/1/2009 6:00:00 AMCare ManagementUnited States of AmericaNew Jersey Department of Health and Senior Services (USA)"Staff failed to determine if correct information had been placed in the electronic medication record regarding a patient with a Stage II pressure ulcer that progressed to Stage IV. The lack of data delayed the system from triggering more services to assist in patient care such as dietary consults, wound care nurse and the use of specialty equipment to aid in reducing the pressure in susceptible skin areas. This short strategy provides actions to reduce risk when caring for patients with pressure ulcers and identified areas where improvements for patient care could be added."5/11/2020 2:12:23 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 https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseHealthcare Associated Infections;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, pressure-relieving pad soins de courte durée, soins de longue durée, soins palliatifs, soins 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
PRESSURE ULCERS1735532161/1/2014 7:00:00 AMCare ManagementUnited States of AmericaMinnesota Hospital Association and Minnesota Department of Health (USA)This alert provides an update on the progress of reduction of patient safety incidents of pressure ulcers in Minnesota. Pressure ulcers happen when a patient’s skin breaks down due to unrelieved pressure or friction They can occur while a patient is in various positions, such as sitting, laying or in surgery. The number of reported pressure ulcers decreased for the second consecutive year, falling from 130 to 95, a 27 percent decrease this year with a 33 percent decrease over the past two years. The highest risk patients are those who have limited mobility, incontinence or circulation problems. Although elderly patients are at a higher risk for pressure ulcers, with patients 75 and older accounting for 19 percent of the reported pressure ulcers, patients ages 65-74 constitute the highest risk category with 24 percent of the events occurring in this population. The majority of reported pressure ulcers were found on the coccyx or sacrum (48 percent), on the head, neck or face (23 percent), or on the heel/ankle/foot (eight percent). Of reported pressure ulcers, 26 percent were device related. This is a 37% decrease since last year. Pressure ulcers related to respiratory devices decreased 10% in the last year and may be related to focused efforts to engage respiratory therapists to use softer oxygen tubing, trialing different masks and using different methods to secure tracheostomy tubes. Hospitals which have reduced or eliminated their use of anti-embolism stockings have achieved zero pressure ulcers related to this device. Interventions which supported significant reductions in pressure ulcer patient safety incidents of two acute hospitals and one long-term care facility are provided. 5/11/2020 2:16:49 AMAES), cervical collar, feeding devices, orthotics, mattress, blood pressure cuffs tube à oxygène, masques, tubes de trachéotomie, bas anti-embolie, collet cervical, dispositifs de https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseHealthcare Associated Infections;Patient Safety Incident
Aggregate review of pressure ulcer incidents 1745632819/16/2014 6:00:00 AMCare ManagementCanadaManitoba HealthAn 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 AMhttps://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
Development of a Pressure Ulcer in a Hospitalized Patient 17678352510/1/2016 6:00:00 AMCare ManagementCanadaManitoba HealthThis alert describes a patient safety incident of development of a pressure ulcer related to patient transfer and incomplete communication of existing orders. The incident is described. A patient was admitted to hospital with respiratory distress. While admitted and being treated for respiratory concerns, the patient also underwent debridement to an existing pressure ulcer. Debridement had not been previously recommended by the patient’s consulting plastic surgeon. Following the debridement, the patient’s wound was graded as a Stage 4 pressure ulcer. A contributing factor was described. The recommendation from the consulting plastic surgeon not to debride the wound was communicated to the receiving hospital at a previous patient admission six months prior, but was not reflected on the transfer referral form sent to the admitting hospital at this admission. System learnings are provided in the alert.5/11/2020 2:18:24 AMTransfert de patient, transition de patient, débridement, transfert de référence, dossier médical électronique, soins de plaies 3https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse