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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 AM
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 PM
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 AM
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 PM
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 AM
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 PM 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 AM
DispForm.aspx91724CommunicationPlace posters and fact sheets about bullying in your break and locker rooms.3687Bullying in Healthcare: A Disruptive Force Linked to Compromised Patient Safety2/11/2019 10:54:53 PM
DispForm.aspx91754CommunicationIf the medication is being used off label, ensure that the patient understands why their doctor chose this medication for them.3686Errors Originating in Hospital and Health-System Outpatient Pharmacies2/11/2019 10:54:57 PM
DispForm.aspx91771CommunicationNotify family.3685Frequent Monitoring and Behavioral Assessment: Keys to the Care of the Intoxicated Patient2/11/2019 10:55:00 PM Management
DispForm.aspx91775CommunicationCreate 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.aspx91807CommunicationClear communication: - Limit interruptions and distractions - Keep remarks objective - Speak using a moderate pace - Verify that the oncoming person understands and accepts transfer of responsibility - Be concise yet thorough - Avoid using jargon, acronyms, or abbreviations - Prepare the report ahead of time - Use briefs or huddles - Identify patient and family needs and concerns - Document handoffs3682Handoff Communications: A Systems Approach2/11/2019 10:55:07 PM Management
DispForm.aspx91817CommunicationNotify the physician immediately for gastrostomy tubes that are suspected or confirmed to be dislodged. Tubes that dislodge within the first 14 days of insertion may need to be replaced surgically. If the gastrocutaneous tract is mature, a new balloon-tipped gastrostomy tube may be inserted at the bedside by qualified personnel.3681Dislodged Gastrostomy Tubes: Preventing a Potentially Fatal Complication2/11/2019 10:55:09 PM Management
DispForm.aspx91824CommunicationEncourage individuals to report unsafe conditions, near misses, and errors due to health information technology so these concerns can be analyzed and ameliorated.3680Medication Errors Attributed to Health Information Technology2/11/2019 10:55:11 PM
DispForm.aspx91830Communication"That staff ensure when transferring patients that they identify all specific tracheostomy tube management issues, discuss these with the receiving ward acknowledging acceptance of patient care and document handover using the nursing handover sheet or equi"NSW19Reducing Incidents Involving Tracheostomy Tube Care6/4/2015 2:11:05 AM
DispForm.aspx91876CommunicationNotify prescribers and pharmacists of any changes (e.g., types of alerts not available or turned off) made to the alerting system in the order entry systems.3674Analysis of Reported Drug Interactions: A Recipe for Harm to Patients2/11/2019 10:55:21 PM
DispForm.aspx91886Communication"Once standardized location for entry of allergy information has been determined, alert staff to always refer to these areas for reliable information."PA079Medication Errors Associated with Documented Allergies6/4/2015 2:11:06 AM
DispForm.aspx91920CommunicationEncourage 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 PM
DispForm.aspx91934CommunicationEmpower staff to “speak up” on behalf of the patient and the surgical team if any team member has questions or concerns.3666Update on Wrong-Site Surgery: Use Patient Engagement to Enhance the Effectiveness of the Universal Protocol2/11/2019 10:55:34 PM3
DispForm.aspx91939CommunicationCommunicate with transferring facilities if a resident has a C. difficile infection.3665Data Snapshot: Clostridium difficile Infections in Long-Term Care Facilities2/11/2019 10:55:35 PM Control
DispForm.aspx91965CommunicationEstablish a multidisciplinary process and accountable personnel to identify and notify contacts, institute visitor restrictions, and coordinate local and state health department and media contacts as necessary.3664Scabies: Strategies for Management and Control2/11/2019 10:55:39 PM Control
DispForm.aspx91970CommunicationUse teach back (or show me) method, which allows providers to confirm understanding by asking the patient to demonstrate or explain, in their own words, what they need to do.3663Health Literacy and Patient Safety Events2/11/2019 10:55:40 PM
DispForm.aspx92011CommunicationProvide awareness to healthcare professionals of the potential for identification errors, such as pulling or entering orders in the wrong medical record.3661Newborns Pose Unique Identification Challenges2/11/2019 10:56:02 PM Identification
DispForm.aspx92048CommunicationStaff could inform the patient or family member that the tourniquet placement is temporary and as a safety measure, involve them in the removal step.3660The Forgotten Tourniquet—An Update2/11/2019 10:56:08 PM Management
DispForm.aspx92053CommunicationCommunication pathways could be developed to inform administration, healthcare workers, and educators about clinical successes and failures. Information from performance audits may reinforce high levels of performance or alert both leadership and front-line staff about system or individual opportunities for improvement.3659A Conceptual Framework for Improving Isolation Awareness in Pennsylvania Acute Care Hospitals2/11/2019 10:56:09 PM Control
DispForm.aspx92055CommunicationVerbally confirm actions of medication administration in presence of instructor or preceptor.3658Medication Errors Involving Healthcare Students2/11/2019 10:56:11 PM
DispForm.aspx92069CommunicationDevelop other communication systems, such as a communication wheel that can be dialed to indicate when the patient will return to the room.3657Missed Respiratory Therapy Treatments: Underlying Causes and Management Strategies2/11/2019 10:56:14 PM Management
DispForm.aspx92079CommunicationSolicit input from patients with dementia and their family members to identify challenges and guide improvement efforts.3656Family Members Advocate for Improved Identification of Patients with Dementia in the Acute Care Setting2/11/2019 10:56:16 PM Identification
DispForm.aspx92100CommunicationMeet with the operating room team, procedure teams and patients to discuss current successes and barriers with implementing best practice.3654Minnesota Patient Safety Alert Regarding Surgery/Procedure Adverse Health Events2/11/2019 10:56:20 PM
DispForm.aspx92104CommunicationConduct face-to-face hand-off communication and sign-outs between senders and receivers in locations free from interruptions, and include multidisciplinary team members and the patient and family, as appropriate.3653Inadequate hand-off communication2/11/2019 10:56:21 PM
DispForm.aspx92119Communication"Provide written information to the patient (e.g., product monograph, part III: Consumer Information), and review instructions with patients and/or patient’s family to ensure that important information is not overlooked and that they understand the risk of inappropriate handling of the product."PC49Transdermal Fentanyl: A Misunderstood Dosage Form6/4/2015 2:11:06 AM
DispForm.aspx92133CommunicationBe aware that there are drugs whose ampoules or packaging are a similar color.3649Drug Mix-up Due to Similar Appearance2/11/2019 10:56:27 PM
DispForm.aspx92139CommunicationWard pharmacists will provide physicians with information about the administration status of anticoagulants/antiplatelet drugs after surgery.3646Forgetting to Resume Anticoagulants/Antiplatelet Drugs2/11/2019 10:56:29 PM
DispForm.aspx92143CommunicationAll staff will be made aware of the reporting procedure in the event that laboratory data are indicative of a panic value.3644Delays in Urgent Contact Regarding Panic Values2/11/2019 10:56:30 PM
DispForm.aspx92152CommunicationProvide a guideline for nurses with regards to when alternate care options may be suggested to patients presenting to an ED.WRHA41Patient with bacterial meningitis leaves an Emergency Department without being seen by ED physician6/4/2015 2:11:06 AM Management
DispForm.aspx92154CommunicationEmphasize the importance and consequences of leaving the award without permission in the information given to parents and guardians of paediatric patients.3639Wrong Infant / Abduction – Mother took baby home without permission2/11/2019 10:56:34 PM
DispForm.aspx92157CommunicationRecommend to the manufacturer to enhance the alert measure of the presence of the preloaded stiffening stylet.3638Retained Instruments / Material – Retained stylet after Port-A-Cath Insertion (2 cases)2/11/2019 10:56:35 PM
DispForm.aspx92164CommunicationEnhance communication between anesthesiologists and nurses for the "SIGN IN" checking.3635Wrong Patient / Part – Wrong sided ilioinguinal nerve block2/11/2019 10:56:38 PM
DispForm.aspx92172CommunicationExplore measures to highlight this risk in published HA treatment guidelines.3630Delayed prescription of antiviral drug to an HBV carrier given high-dose corticosteroid therapy2/11/2019 10:57:02 PM Management
DispForm.aspx92182CommunicationReinforce 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.aspx92190CommunicationEnhance staff awareness on the “Risk register of high risk instruments”.3626Retained Instruments / Material - Metallic fragments2/11/2019 10:57:06 PM
DispForm.aspx92211CommunicationAlert all stakeholders on the risk of used instrument.3614Retained Instruments / Material - Broken metallic wire2/11/2019 10:57:15 PM
DispForm.aspx92222CommunicationShare 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.aspx92240CommunicationEnhance awareness on the potential risk of breakage of surgical instruments.36053604 Retained Instruments / Material -- Radiopaque fragment in LEFT wrist2/11/2019 10:57:23 PM
DispForm.aspx92241Communication"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.aspx92244CommunicationIncrease staff alertness on the risk of a broken and retained NG tube in the patient’s airway to ensure timely management of possible retention.3604Retained Instruments / Material – Broken nasogastric (NG) tube2/11/2019 10:57:24 PM3 Management
DispForm.aspx92247CommunicationEnhance communication and speak up culture among team members, including completion of final instrument count before reversal of anesthesia.3603Retained Instruments / Material -- Rubber cap of intra-uterine cannula2/11/2019 10:57:25 PM Labour and Delivery
DispForm.aspx92261CommunicationRemind orthopaedic surgeons to reinforce the practice of examining broken instruments with due diligence instead of only performing visual checking on surgical field.3597Retained Instruments / Material – Coil wire fragments2/11/2019 10:57:49 PM
DispForm.aspx92283CommunicationEnhance alertness of surgeons on retained foreign body while reviewing intraoperative imaging.3589Retained Instruments / Material – A Kirschner wire (K-wire) tip2/11/2019 10:57:56 PM
DispForm.aspx92291CommunicationShare the incident to raise awareness on the risk.3585Retained Instruments / Material - Plain gauze2/11/2019 10:57:59 PM Labour and Delivery