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DispForm.aspx20613CommunicationEncourage prescribers to report CPOE-related errors including incorrect or incomplete clinical decision support information and develop a standard process to make timely safety and quality enhancements.3667Prescribing Errors that Cause Harm2/11/2019 10:55:31 PM10
DispForm.aspx19938Rules / Policies / ProceduresCheck the patient against the blood product when you are beside the patient, immediately before administration.3643Blood Transfusion to Wrong Patient (1st Follow-up Report) 2/11/2019 10:56:31 PM Products/Transfusion
DispForm.aspx19974CommunicationReinforce the message to patients and their visitors of the importance and need for informing clinical staff before leaving the ward.3628Inpatient suicide2/11/2019 10:57:04 PM
DispForm.aspx19995TrainingDevelop an education plan for staff to ensure Special Care Unit & Rapid Response Physician (SCU/RRP) policy is implemented regionally.3797Delay in Treatment9/16/2019 8:23:29 PM Management
DispForm.aspx20036Rules / Policies / ProceduresProne restraint must only be used as a last resort.3535Use of Prone Restraint and Parenteral Medication in Healthcare Settings2/11/2019 11:02:12 PM
DispForm.aspx20064Rules / Policies / ProceduresPatients’ drug allergy history should be entered into the clinical management system immediately.3616Medication Error - Known Drug Allergy – Low alertness of reported allergy2/11/2019 10:57:14 PM
DispForm.aspx20077CommunicationShare the lesson learned with involved departments to facilitate multidisciplinary management of critically ill patients.3610Maternal Morbidity – Case 22/11/2019 10:57:18 PM Labour and Delivery
DispForm.aspx20092Rules / Policies / ProceduresRevise the workflow of obtaining informed consent.3606Wrong Patient / Part – Removal of wrong side double J (JJ) stent2/11/2019 10:57:22 PM
DispForm.aspx20096Communication"Alert all staff that pass medication, that the devices that come in the box for liquid risperidone are considered pipettes by the company, although would normally be thought of as syringes by our frontline users. The markings are opposite of the syringes we are used to, and they are on the plunger of the pipettes. If possible, DO NOT USE THEM."VA03Risperidone oral medication syringe (pipette)6/4/2015 2:11:06 AM
DispForm.aspx20106Rules / Policies / ProceduresPerform the procedure properly in accordance with standard practice.3601Retained Instruments / Material – Guide wire2/11/2019 10:57:46 PM Management
DispForm.aspx20171Rules / Policies / ProceduresVancomycin must be diluted (at least 500mg/100mL) and administered by slow IV infusion (no more than 10mg/minute).3575Vancomycin given as intravenous (IV) bolus2/11/2019 10:58:07 PM
DispForm.aspx20174Communication"An intervention be implemented to ensure that there is documentation to show that staff have informed patients about call bell use and that staff have ensured patients have a mechanism in place at all times to either call for or alert staff (i.e. call bell, bed sensor)."WRHA2A delayed diagnosis of a shoulder dislocation following an unwitnessed fall by an elderly patient receiving narcotics6/4/2015 2:11:07 AM
DispForm.aspx20185Environment / EquipmentInspect all Kendall SCD tubing sets to confirm that none of the recalled sets remain on site (identification instructions are attached). Either positively identify “blank” (no lot number label) tubing sets for proper connectors or treat them as suspect. VA11Kendall Connection Tubing Sets6/4/2015 2:11:07 AM
DispForm.aspx20195Regulation / LegislationDisplay prominently the drug allergy card in patient’s record folder3565Medication Error - Known drug allergy2/11/2019 11:01:24 PM
DispForm.aspx20202Rules / Policies / ProceduresEnhance awareness.3563Retained K-wire fragment after wrist arthroscopy2/11/2019 11:01:25 PM
DispForm.aspx20215Rules / Policies / ProceduresIdentify if oxygen cylinders are used in your organisation, even if only in emergencies.3558Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders11/4/2021 2:38:16 PM
DispForm.aspx20225Regulation / LegislationIdentify if TPN is used in your neonatal and paediatric departments.3556Risk of severe harm and death from infusing total parenteral nutrition too rapidly in babies2/11/2019 11:01:29 PM
DispForm.aspx20233CommunicationBring this Alert to the attention of those holding leadership roles for the safe transition to NRFit™ connectors.3555Resources to support safe transition from the Luer connector to NRFit™ for intrathecal and epidural procedures, and delivery of regional blocks2/11/2019 11:01:30 PM
DispForm.aspx20240Rules / Policies / ProceduresEducation of junior medical staff to communicate with senior medical staff condition of patients admitted under their care. VIC018Potential for error – communication issues6/4/2015 2:11:07 AM Management
DispForm.aspx20249Rules / Policies / ProceduresIdentify whether incidents involving inappropriate use of insulin pen devices could occur in your organisation.3551Risk of severe harm and death due to withdrawing insulin from pen devices2/11/2019 11:01:33 PM
DispForm.aspx20258Rules / Policies / ProceduresIdentify if the issues in this alert could occur in your organisation.3550Risk of death and severe harm from error with injectable phenytoin2/11/2019 11:01:34 PM
DispForm.aspx20282Rules / Policies / ProceduresIdentify a senior clinical leader in the organisation to take forward the response to this alert.3545Resources to support safer care of the deteriorating patient (adults and children)2/11/2019 11:01:38 PM Management
DispForm.aspx20295Rules / Policies / ProceduresIdentify if the omission of desmopressin for the treatment of cranial diabetes insipidus has or could occur in your organisation.3541Risk of severe harm or death when desmopressin is omitted or delayed in patients with cranial diabetes insipidus2/11/2019 11:01:40 PM
DispForm.aspx20317Rules / Policies / ProceduresComplete applicable admission forms/tools within 12 hours of admission. Re-evaluate all applicable forms/tools including but not limited to the Braden Scale for Predicting Risk of Pressure Injuries.3793Pressure Injury9/16/2019 8:23:33 PM Ulcer
DispForm.aspx20325Rules / Policies / ProceduresEnsure prescribers document on the order which "dosing weight" (i.e., actual, ideal, or adjusted body weight) will be used to calculate the dose of the chemotherapy.3697Medication Errors in Outpatient Hematology and Oncology Clinics2/11/2019 10:53:54 PM
DispForm.aspx20331Rules / Policies / ProceduresPrior to bringing on new processes/systems: Promote event reporting. Collect and analyze all reports, and specifically near-misses, to help identify patient safety hazards and detect existing system weaknesses. Establish a baseline of performance before implementation to provide a means of comparison for like events during and after implementation.3695Near-Miss Event Analysis Enhances the Barcode Medication Administration Process2/11/2019 10:53:55 PM
DispForm.aspx20368Environment / EquipmentStorage of amphotericin B products in patient care areas and automated dispensing equipment is discouraged.ISMPC41WARNING: Prevent Mix-ups between Conventional amphotericin B (Fungizone®) and Lipid-based amphotericin B products (AmBisome® or Abelcet®)6/4/2015 2:11:05 AM
DispForm.aspx20369Rules / Policies / ProceduresVisually inspect the product for discoloration and particulate matter prior to administration.3689Radiology Contrast Concerns: Reports of Extravasation and Allergic Reactions 2/11/2019 10:54:50 PM Imaging
DispForm.aspx20396Rules / Policies / ProceduresManagers should consult with Facilities Maintenance/Clinical Engineering about the types of bed alarms in use to determine configuration practices and develop the most appropriate plan for regular audits/maintenance of alarms.3719Bed Alarms-Safe use and configuration2/11/2019 10:53:35 PM
DispForm.aspx20401Training"Educate all staff that glacial acetic acid is never used for medical purposes, and that glacial acetic acid is the most concentrated form of acetic acid. The Material Safety Data Sheet and container label can be used to emphasize the dangers of this chemical."PA065Glacial Acetic Acid: Doing More Harm than Good?6/4/2015 2:11:05 AM
DispForm.aspx20412Communication"Good communication from the hospital providing the prescription for therapy to the hospital where treatment will be administered can help ensure advance planning for the patient visit. Different hospitals can have very different medication formularies. In this case the small urban hospital uses Solu-cortef more often than Solu-Medrol and nursing staff were therefore less familiar with the Solu-Medrol product. Ideally, in situations where an out-patient visit is scheduled, the required medication can be selected by pharmacy personnel in advance of the patient visit. A pharmacist-dispensed product provides an extra layer of safety."ISMPC37Depo-Medrol® Confused with Solu-Medrol®6/4/2015 2:11:05 AM
DispForm.aspx20462Rules / Policies / ProceduresImplementing screening for alcohol dependent drinkers and providing brief intervention for those who screen positive or at-risk for alcohol dependency is shown to reduce the quantity of alcohol consumed and re-visits to the ED.3685Frequent Monitoring and Behavioral Assessment: Keys to the Care of the Intoxicated Patient2/11/2019 10:55:00 PM Management
DispForm.aspx20468CommunicationCreate a Regional Advisory Committee that includes broad representation from all relevant sectors.WRHA19Delayed surgical specimen pick-up resulted in patient requiring an artificial skull plate6/4/2015 2:11:05 AM
DispForm.aspx20479Rules / Policies / Procedures"Make the organization's overall safety performance a key, measurable part of the evaluation of the CEO and all leadership."JC05Leadership committed to safety6/4/2015 2:11:05 AM Administration/Documentation
DispForm.aspx20498Rules / Policies / ProceduresStandardize inconsistent processes: - Develop and update handoff policies and procedures - Map the handoff process - For handoffs, provide opportunities for face-to-face communications to seek clarification and discuss questions - Create a handoff tool or considering using a standardized handoff tool: SBAR I-PASS IPASS the BATON Ticket to ride - Perform physical checks of the patient and equipment (e.g., IV lines) during a handoff - Include patient and family in discussions of plans and goals - Tailor the handoff to the unit - Standardize the discharge process3682Handoff Communications: A Systems Approach2/11/2019 10:55:07 PM Management
DispForm.aspx20568Rules / Policies / ProceduresProtocol/procedure development for the management of emergency patients in OR until formal management plan is drafted. VIC020Potential for error – coordination of care6/4/2015 2:11:06 AM Management
DispForm.aspx20585Rules / Policies / ProceduresReducing the use of blood and using blood-conservation techniques during surgery help reduce the risk of adverse reactions by reducing the need for transfusions.3669Blood Transfusion Events—Lessons Learned from a Complex Process2/11/2019 10:55:26 PM Products/Transfusion
DispForm.aspx20660Rules / Policies / ProceduresScreen patients for cognitive impairment.3663Health Literacy and Patient Safety Events2/11/2019 10:55:40 PM
DispForm.aspx20689Environment / EquipmentEnsure all patient care areas have the necessary equipment to easily obtain an accurate patient weight, including weights for infants and children, as appropriate. Examples of possible equipment include floor scales, stretchers and beds with built-in scales, and standing, chair, and wheelchair scales.3662Update on Medication Errors Associated with Incorrect Patient Weights2/11/2019 10:55:45 PM
DispForm.aspx20700Rules / Policies / ProceduresMake important information legible and prominent on identification bands, the electronic health record screen, and the specimen label.3661Newborns Pose Unique Identification Challenges2/11/2019 10:56:01 PM Identification
DispForm.aspx20747TrainingEnsure students participating in the medication-use process are appropriately supervised by faculty or preceptors during their clinical rotations. This includes having the instructor or preceptor present at the bedside during the time of medication administration.3658Medication Errors Involving Healthcare Students2/11/2019 10:56:11 PM
DispForm.aspx20755Rules / Policies / ProceduresUse assessment and treatment protocols that allow respiratory therapists to evaluate patients, interact with physicians to minimize unnecessary care, and optimize care ordered by the physician.8 Initiate or modify a patient’s care plan following the set of physician orders, including instructions or interventions that the respiratory therapist can adjust as the patient’s medical condition dictates.3657Missed Respiratory Therapy Treatments: Underlying Causes and Management Strategies2/11/2019 10:56:13 PM Management
DispForm.aspx20771Rules / Policies / ProceduresAssemble a multidisciplinary team to design improved care processes for patients with dementia. Suggested members include a physician and nurse with dementia expertise (i.e., specialization in geriatrics, neurology, or psychiatry), a social worker, and administrative staff.3656Family Members Advocate for Improved Identification of Patients with Dementia in the Acute Care Setting2/11/2019 10:56:15 PM Identification
DispForm.aspx20801Rules / Policies / Procedures"Provincial and Regional Health Authorities will meet to devise a contingency plan for situations when a child/family is directed to a distant health care facility for diagnostic services necessitating land transportation, when such is not available."WRHA15Delayed diagnosis of an unusual vascular complication following varicella in a child6/4/2015 2:11:06 AM Management
DispForm.aspx20803Rules / Policies / ProceduresAbsolutely crucial is a transparent, non-punitive approach to reporting and learning from adverse events, close calls and unsafe conditions.3652The essential role of leadership in developing a safety culture11/4/2021 2:29:23 PM
DispForm.aspx20833Rules / Policies / ProceduresThe institution will prepare a manual for the removal of central venous catheters. - Place the patient in the supine position or Trendelenburg position. - Have the patient take a breath and hold it, then remove the catheter. - Apply pressure to the site from which the catheter was removed for at least five minutes. - Cover the site from which the catheter was removed with a highly occlusive dressing.3645Air Embolism after Removal of a Central Venous Catheter2/11/2019 10:56:30 PM Management
DispForm.aspx20834Rules / Policies / ProceduresThe operative site is marked. See Directive for further information.VA61Ensuring Correct Surgery and Invasive Procedures6/4/2015 2:11:06 AM
DispForm.aspx20930Rules / Policies / ProceduresImplement wound prevention interventions that are consistent with the client’s needs and recognized standards of best practice.3768Stage 3-4 Pressure Injuries in Long Term Care Residents9/17/2019 3:59:50 PM Ulcer
DispForm.aspx20938TrainingKeep technicians in the information loop regarding safe medication administration practices by providing in-service education.PA082Medication Errors Occurring in the Radiologic Services Department6/4/2015 2:11:09 AM
DispForm.aspx20948Rules / Policies / ProceduresIdentify an appropriate clinical leader to co-ordinate implementation of this alert.3846Resources to support safer bowel care for patients at risk of autonomic dysreflexia12/1/2021 2:38:54 PM Management