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DispForm.aspx48544CommunicationUnderstand that we are #InThisTogether to make sure there is enough medication for everyone. Work with your doctor, dentist, nurse practitioner, or other prescriber to have enough medication to last 30 days. If you have special circumstances that require you to have more than 30 days of medication on hand, let your prescriber know. Ask the prescriber to include the reason on your prescription.3907You Can Make a Difference: Help Prevent Medication Shortages6/15/2020 4:00:08 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCOVID-19
DispForm.aspx48927CommunicationMaintain staff awareness of the correct high-level disinfectant to use, proper timing, rinsing, and drying.3892Inadvertent Endoscope Contamination Can lead to Patient Infections7/9/2020 3:34:50 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseInfection Control
DispForm.aspx48934CommunicationFollow Oregon AWARE on Facebook to get regular updates on injection and needle safety and antimicrobial stewardship.3891Injection Safety and Needle Use in Oregon7/9/2020 3:34:50 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseOther
DispForm.aspx48953CommunicationEmploy multiple communication methods to keep affected healthcare providers informed of the status of drug shortages in a timely manner. For example, communication through the EHR may be used to alert clinicians of a shortage situation at the point of prescribing and to suggest a therapeutic alternative.3886Drug Shortages: Shortchanging Quality and Safe Patient Care7/9/2020 3:34:52 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49000CommunicationTimely follow-up phone calls.3883From the Database: Deaths after Ambulatory Surgery7/9/2020 3:34:55 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseSurgery
DispForm.aspx49050CommunicationInterview patients and review their medical records, including previous radiologic or MR imaging, to determine the presence of any internal medical devices or nonmedical objects.3880MRI Screening: What’s in Your Pocket?7/9/2020 3:34:58 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseDiagnostic Imaging
DispForm.aspx49103CommunicationUse barcode scanning to confirm that the medication selected for distribution to the ADC and placed in the ADC matches the medication listed on ADC fill report.3877The Breakup: Errors when Altering Oral Solid Dosage Forms7/9/2020 3:35:03 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49148CommunicationWhen a new anticoagulant is added to the organization's formulary, notify staff using tools such as newsletters and in-services. Studies show that even with continuous offerings for educational programs on therapeutic agents, healthcare professionals find it difficult to keep completely up to date through independent effort. Therefore, providing relevant and reliable information at the time that it is needed for patient care may be helpful.3874Identifying Patient Harm from Direct Oral Anticoagulants7/9/2020 3:35:07 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49167CommunicationReport any cases of invasive group A streptococcus (iGAS) infection through the Pennsylvania National Electronic Disease Surveillance System (PA-NEDSS). If you are unsure whether a case from your facility has been reported, or if you are seeking guidance, call your local district office or state health center. You may also call 1-877-PA-HEALTH to be directed to the correct office.3871Data Snapshot: Group A Streptococcus in Pennsylvania Long-Term Care Facilities7/9/2020 3:35:09 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseInfection Control
DispForm.aspx49253CommunicationShare your reviewed local guidance, advice on how to identify staff who can provide digital removal of feces, and the key messages in this alert with medical, nursing and other relevant clinical staff.3846Resources to support safer bowel care for patients at risk of autonomic dysreflexia7/9/2020 3:36:14 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCare Management
DispForm.aspx49258CommunicationThrough a local communications strategy (e.g. newsletters, local awareness campaigns etc) ensure that all relevant staff are aware of relevant IDDSI resources and importance of eliminating imprecise terminology including ‘soft diet’, and understand their role in the local implementation plan.3845Resources to support safer modification of food and drink7/9/2020 3:36:15 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCare Management
DispForm.aspx49261CommunicationBring this alert to the attention of all those with a leadership role in responding to patient deterioration, including critical care outreach teams.3844Resources to support the safe adoption of the revised National Early Warning Score (NEWS2)7/9/2020 3:36:16 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCare Management
DispForm.aspx49267CommunicationBring this alert to the attention of all those with a leadership role in surgery, operating theatres, intensive care and pharmacy.3843Risk of death or severe harm from inadvertent intravenous administration of solid organ perfusion fluids7/9/2020 3:36:17 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49315CommunicationThe importance of educating clerical and nursing staff on the importance of communicating referral cancellations to the referring physician requires reinforcement.3834Missed Amended Pathology Report7/9/2020 3:36:42 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCare Management
DispForm.aspx49321CommunicationTalk to your doctor or pharmacist if you have any questions about changing to a different or a new medication.3832When Medications Are Not Available Due to a Drug Shortage7/9/2020 3:36:43 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49328CommunicationUse the “5 Questions to Ask about Your Medications” to get the information you need to understand all of your medications.3831Biologics and Biosimilars: What You Need to Know7/9/2020 3:36:44 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49332CommunicationFor each of your medications, ask your health care provider what side effects you should watch for. This information can help you notice health changes that might be due to your medication. Use the 5 Questions to Ask to start a conversation with your health care provider.3830Protecting Canadians from Unsafe Drugs Act What It Means for You7/9/2020 3:36:45 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49338CommunicationWhen you go to a pharmacy, hospital, or other healthcare setting always identify yourself using your full name and at least one other piece of information. The additional information can be your date of birth, your home address, or your health card number.3829Mistaken Identity – A Recurring Problem7/9/2020 3:36:46 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49349CommunicationShare your medication list with your new doctor.3828How to Safely Transfer Your Prescriptions7/9/2020 3:36:47 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49352CommunicationIf you see a label warning about sun exposure on your prescription vial, ask your pharmacist about precautions you should take to prevent a skin reaction.3827Sun-Sensitive Medications7/9/2020 3:36:48 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49362CommunicationAsk to add the medication’s expiry date to the label of a prescription vial if you will not be using the medication regularly. Most medications provided in a prescription vial do not include an expiry date on the label.3826You Asked Us: Checking Medication Expiry Dates 7/9/2020 3:36:50 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49368CommunicationYour healthcare team: If you have any questions or concerns about your medications, or you simply want more information, talk to your doctor, nurse, or pharmacist. These healthcare professionals will be able to answer your questions or guide you in the right direction.3825Consumer "Good Catches" – Part 2: Know Where to Look7/9/2020 3:36:51 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49375CommunicationDo not be afraid to ask questions. Talk to a healthcare provider if anything is not what you expected.3824Consumer “Good Catches” – Part 1: Know What to Expect7/9/2020 3:36:52 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49392CommunicationCommunicating the rate in terms of both the amount of drug (milliunits/minute) and the volume (millilitres/hour) to be infused provides more clarity and less opportunity for misinterpretation.3822Errors Associated with Oxytocin Use: A Multi-Incident Analysis 7/9/2020 3:36:54 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49403CommunicationTo healthcare facilities: Advise healthcare providers (including prescribers, dietitians and speech language pathologists) to consider and warn about this interaction when making recommendations about texture of diet or use of thickeners.3821Potentially Harmful Interaction between Polyethylene Glycol Laxative and Starch-Based Thickeners7/9/2020 3:36:55 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49416CommunicationFor Pharmacy Regulatory Authorities: Actively promote the use of the standardized documentation, beyond offering guidelines, examples, or options.3818Lack of Standardized Documentation Contributes to a Mix-up between Methadone and Buprenorphine-Naloxone7/9/2020 3:36:58 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49431CommunicationDesign the discharge prescription and discharge summary forms to include contact information for the most responsible physician, the discharging nursing unit, and the hospital pharmacist, to facilitate clarification of medication queries after hospital discharge.3816Gaps in Interconnectivity of a Hospital’s Electronic Systems Create Vulnerabilities at Transitions of Care7/9/2020 3:37:00 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49454CommunicationDevelop a contingency plan to be activated in the event of a drug shortage and/or change in supplier. The contingency plan should include a communication process to notify all staff before the “new” product is made available, as well as a prospective consideration of potential errors that could result from the product change. This communication should be printed and kept with the stock, in addition to other electronic and printed material.3815Preventable Tragedies: Two Pediatric Deaths Due to Intravenous Administration of Concentrated Electrolytes7/9/2020 3:37:03 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx49488CommunicationFor hospitals: Inform the Microbiology department that a patient is being screened for C. auris as it can easily be misidentified.3812Candida auris infection considerations for the transfer or repatriation of an overseas patient to a NSW hospital7/9/2020 3:37:08 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseInfection Control
DispForm.aspx49492CommunicationReview Massive Transfusion Protocols (MTP) to ensure that: - Clinical staff are informed that the ABO compatibility for Plasma Products is different to that of red cells.3811ABO Compatibility for Blood Products in an Emergency7/9/2020 3:37:09 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseBlood Products/Transfusion
DispForm.aspx60927CommunicationFor consumers: Call the local poison centre if you believe anyone in your household has swallowed any amount of hand sanitizer. This step is especially important if children are involved. To find a list of all local poison centres in Canada, see the “Provincial Centres” tab at http://www.capcc.ca/en. Write down the number for your local centre, and keep it in a handy spot.3904ALERT: Hand Sanitizers That Look Like Drinks7/22/2020 4:18:06 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCOVID-19
DispForm.aspx60940CommunicationEvaluate options for telephone, video-calling, and email communication according to the hospital’s capabilities, as well as the patient’s own resources or limitations. Consider the availability, security, and practicality of internet access, email accounts (both hospital and patient’s personal emails), in-room telephone, mobile phone, internet-based video-calling platform, intercom, or 2-way communicating baby monitors.3903Virtual Medication History Interviews and Discharge Education7/22/2020 4:17:41 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCOVID-19
DispForm.aspx61095CommunicationInform latex allergic patients and families of your organization's efforts to reduce latex exposure risk and engage them as partners in monitoring the environment and reminding all members of the care team about their allergy.3869Latex: A Lingering and Lurking Safety Risk7/9/2020 3:35:46 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCare Management
DispForm.aspx61117CommunicationThe Medical Center Director shall ensure that staff involved with the prescription, supply, and monitoring of home oxygen therapy are made aware of this Patient Safety Alert. Such staff may include, but are not limited to, primary care providers, respiratory therapists, pulmonologists, contracting staff, home oxygen coordinators, home care staff, prosthetics staff, IntegratedEthics® staff, occupational safety and health staff, the home oxygen delivery system vendor staff, and appropriate VISN level staff.3868Use of thermal fuses may reduce the severity of fires involving home oxygen delivery systems7/9/2020 3:35:50 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedical Gas
DispForm.aspx61128CommunicationCreate name awareness for the various kinds of DOACs — apixaban (Eliquis®), betrixaban (Bevyxxa®), dabigatran (Pradaxa®), edoxaban (Savaysa®), and rivaroxaban (Xarelto®) — particularly among pharmacists, emergency department clinicians and providers who may be called upon to rapidly reverse life-threatening bleeding.3867Managing the risks of direct oral anticoagulants7/9/2020 3:35:52 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx61160CommunicationMedical personnel will ascertain the patient’s clinical condition and share patient information with each other.3862Falls from an Examination Table7/9/2020 3:35:58 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseFalls
DispForm.aspx61168CommunicationTo provide patients with information, the total dosage will be noted on their medication notebook and this will be explained.3861Administration of an Antineoplastic Agent in Excess of the Total Dosage Limit7/9/2020 3:35:59 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx61214CommunicationEnsure all relevant staff are aware of the key messages in this alert and the new or updated local protocols/easy reference guides through routes such as team updates, newsletters, local awareness campaigns, etc.3852 Assessment and management of babies who are accidentally dropped in hospital7/9/2020 3:36:07 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCare Management
DispForm.aspx61221CommunicationCommunicate the key messages in this alert and your organisation’s plan for managing those risks to all relevant medical, nursing and theatre staff.3851Wrong selection of orthopaedic fracture fixation plates7/9/2020 3:36:08 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseSurgery
DispForm.aspx61228CommunicationOnce your organisation’s action plan for managing these risks has been agreed, communicate the key messages in this alert and the plan to relevant clinical staff, clinical education/training staff, and patients or their carers who self-monitor oxygen saturation levels.3850Risk of harm from inappropriate placement of pulse oximeter probes7/9/2020 3:36:09 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseDevice
DispForm.aspx61238CommunicationCommunicate the key messages in this alert and your organisation’s plan for safer identification systems to all relevant staff.3849Safer temporary identification criteria for unknown or unidentified patients7/9/2020 3:36:11 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalsePatient Identification
DispForm.aspx61243CommunicationUse local communication strategies (such as newsletters and awareness campaigns, etc) to ensure that all relevant staff and patients are aware of and have access to these resources.3848Management of life threatening bleeds from arteriovenous fistulae and grafts7/9/2020 3:36:12 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCare Management
DispForm.aspx61250CommunicationUse local communication strategies (such as the videos, newsletters, local awareness campaigns, etc) to make all staff aware that hyperkalaemia is a potentially life-threatening emergency and that its timely identification, treatment and monitoring during and beyond initial treatment is essential.3847Resources to support safe and timely management of hyperkalaemia (high level of potassium in the blood)7/9/2020 3:36:13 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseCare Management
DispForm.aspx91629Communication"Prescribers should provide clear dosing instructions, avoiding phrases such as "use as directed". In consultation with the patient, choose a particular day of the week when the medication is to be taken, and specify this day on the prescription. However, avoid choosing Monday as the designated day, as this word has reportedly been misinterpreted as "morning". - Consider including the indication for methotrexate use on prescriptions, as helpful information for other health care providers (e.g., pharmacists and nurses). - When possible, for patients living in the community, consider limiting quantities to be dispensed to a one month supply at a time."ISMPC11Incidents of Inadvertent Daily Administration of Methotrexate6/4/2015 2:11:05 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx91640CommunicationPrior to bringing on new processes/systems: Communicate with and involve frontline staff. Facilities adopting medication management–related technologies, whether stand-alone or integrated, can consider the technologies' interconnectedness and functionality for the end user.3695Near-Miss Event Analysis Enhances the Barcode Medication Administration Process2/11/2019 10:53:55 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx91642Communication"Inform clinicians/users that: a. When entering or editing numerical values on the programming screen, (e.g., dose rate, flow rate, volume to be infused) the numbers should be entered in their entirety, even if the previous numerical value exists on the screen or if a single digit was entered in error. b. All data entries should be verified before starting any infusions. c. If provided, Guardrails software soft-limit warnings should not be overridden without first verifying the rate they entered is what was ordered."VA44Cardinal Health’s Alaris System Infusion Pumps6/4/2015 2:11:05 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseDevice
DispForm.aspx91660CommunicationEngage stakeholders in continuum of care stewardship efforts. • Establish relationships with hospital antibiotic stewardship teams to improve understanding of the rationale for antibiotics prescribed and to streamline availability of hospital testing results. • Work with consultants such as behavioral health and dialysis to establish stewardship goals and protocols. • Educate and engage families and residents in the stewardship plan.3692Optimal Use of Antibiotics for Urinary Tract Infections in Long-Term Care Facilities: Successful Strategies Prevent Resident Harm2/11/2019 10:53:58 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication
DispForm.aspx91664CommunicationClear labelling of the sockets for essential power and message not to unplug the socket must be in place.HK015Incidental Unplugging of Power Supply of Essential Equipment in General Wards6/4/2015 2:11:05 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseDevice
DispForm.aspx91694CommunicationNotify most responsible physician/ nurse practitioner.3720Timely response and follow-up after patient exposure to blood and bodily fluids2/11/2019 10:53:34 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseInfection Control
DispForm.aspx91719Communication"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 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Recommendations/AllItems.aspxFalseMedication