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DispForm.aspx349Training- Users of automatic contrast media injectors should be limited to those who have been trained for the proper use of contrast media and the risk of air embolism. - Periodic competency(correct use of contrast media) tests on users of automatic contrast media injector should be performed.3910A fatal risk caused by carelessness in the use of an automatic contrast media injector9/23/2020 8:33:38 PM Management
DispForm.aspx48555Rules / Policies / ProceduresFor prescribers: Allow sufficient time to state the order clearly and for the person receiving it to read it back.3905Strategies for Safer Telephone and Other Verbal Orders in Defined Circumstances7/22/2020 4:18:31 PM
DispForm.aspx48949Rules / Policies / ProceduresDevelop an ongoing strategy to prepare for drug shortages, standardize how shortages are approached, communicate to stakeholders updates on shortages (as well as changes in practice as a result of shortages), and monitor interventions that are implemented (i.e., choosing an alternative drug).3886Drug Shortages: Shortchanging Quality and Safe Patient Care7/9/2020 3:34:51 PM
DispForm.aspx48960TrainingAssess nonpsychiatric staff members' comfort, knowledge, and competence caring for patients at risk of self-harm. Based on each role's scope of practice, education may focus on dialoguing with patients about self-harm behaviors, identifying environmental hazards, using de-escalation techniques, or implementing appropriate risk reduction strategies.3885Patient Self-Harm in the Nonpsychiatric Setting7/9/2020 3:34:52 PM Protection
DispForm.aspx48989Rules / Policies / ProceduresImproved preoperative screening of patients, with particular emphasis on comorbidities and risk factors, and communication with scheduling providers.3883From the Database: Deaths after Ambulatory Surgery7/9/2020 3:34:54 PM
DispForm.aspx49005Regulation / LegislationCurrent guidelines for massive transfusion protocol include: - Protocol triggers for MTP activation and deactivation - Algorithm for preparation and delivery of blood products (including plasma) in all settings - Transfusion targets - Use of pharmacologic hemostatic agents - Ongoing evaluation of cumulative MTP performance3882Are You Ready to Respond? Reports of High Harm Complications after Surgery and Invasive Procedures7/9/2020 3:34:55 PM
DispForm.aspx49028Rules / Policies / ProceduresEmploy bar-code medication administration (BCMA) across all patient care areas, including intraoperative areas and the PACU, as a system-wide, high-leverage strategy to prevent errors. Standardize the workflow for electronic entry of intraoperative orders to support BCMA. Consider implementing barcode-assisted syringe labeling systems, which replace manual syringe labeling by producing a label upon product scan at the time that the medication is drawn up into a syringe, in order to facilitate use of BCMA.3881Perioperative Medication Errors: Uncovering Risk from Behind the Drapes7/9/2020 3:34:56 PM
DispForm.aspx49038Rules / Policies / ProceduresDesignate an MR safety officer and/or medical director responsible for ensuring that MRI safety policies and procedures are in place and monitored for compliance.3880MRI Screening: What’s in Your Pocket?7/9/2020 3:34:57 PM Imaging
DispForm.aspx49046Environment / EquipmentComing soon3902COVID-19 Alerts, Advisories and Recommendations Coming Soon5/11/2020 3:39:26 AM
DispForm.aspx49072TrainingProvide information on optimal pulmonary state.3879A Second Breadth: Hospital-Acquired Pneumonia in Pennsylvania, Nonventilated versus Ventilated Patients7/9/2020 3:35:00 PM Management
DispForm.aspx49094Rules / Policies / ProceduresLimit altering oral solid dosage forms to cases in which commercially available alternatives are unavailable, especially for high-alert and narrow therapeutic index drugs.3877The Breakup: Errors when Altering Oral Solid Dosage Forms7/9/2020 3:35:02 PM
DispForm.aspx49129Rules / Policies / ProceduresA review of the literature found articles describing use of verification processes and checklists for imaging studies that are similar to those used in surgery. For example, Rubio and Hogan found that implementing a brief two-person verification approach significantly decreased wrong-patient and wrong-study radiology events. A presentation at the Radiological Society of North America 2015 annual meeting reported that a hospital in the Generations and Northern Manhattan Network of Bronx, New York, implemented a "Radiology Exam Verification and Time Out" process. This time-out by the radiology technologist and another healthcare provider occurs at the location of the study (e.g., radiology area, neonatal unit, emergency department) and includes a two-person verification of patient identifiers, procedure to be performed, site, laterality, site marking, contrast (orders and expiration date if applicable) and pregnancy screening. Both the technologist and witness initial each item of verification then sign an acknowledgement that all the steps of verification were completed.3876Adapting Verification Processes to Prevent Wrong Radiology Events7/22/2020 4:19:36 PM Imaging
DispForm.aspx49138Rules / Policies / ProceduresWhen an oral anticoagulant is indicated, before initiating therapy, collect and make readily available baseline patient information including patient weight (in metric units) and laboratory test results such as renal and liver function.3874Identifying Patient Harm from Direct Oral Anticoagulants7/9/2020 3:35:07 PM
DispForm.aspx49155Rules / Policies / ProceduresThree elements are necessary for a fire: a heat source, oxygen, and a fuel. The surgeon is usually in control of the heat source, most commonly an electrosurgical unit, and can remove it from the field. The anesthesia professional is usually in control of the supplemental oxygen source and can minimize the oxidizer component of the fire triangle. The scrub technician can help ensure meticulous application of alcohol-containing skin prepping solutions and confirm that they are dry before the application of surgical towels and drapes.3873Surgical Fires: Decreasing Incidence Relies on Continued Prevention Efforts7/9/2020 3:35:08 PM
DispForm.aspx49180Rules / Policies / ProceduresTo decrease the risk of healthcare-associated burns, determine whether there are current strategies and policies for assessing and recognizing patient and environmental factors that add risk for burns.3870Hot Topic: Nonsurgical, Healthcare-Associated Burn Injuries7/9/2020 3:35:10 PM Management
DispForm.aspx49245Rules / 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 dysreflexia7/9/2020 3:36:14 PM Management
DispForm.aspx49256Rules / Policies / ProceduresIdentify a senior clinical leader who will bring together key individuals (including speech and language therapists, dietitians, nurses, medical staff, pharmacists and catering services) to plan and co-ordinate safe and effective local transition to the IDDSI framework and eliminate use of imprecise terminology including ‘soft diet’.3845Resources to support safer modification of food and drink7/9/2020 3:36:15 PM Management
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 PM Management
DispForm.aspx49318Rules / Policies / ProceduresImplement a process where all necessary diagnostic imaging is visualized as a confirmation of the task prior to surgical procedures.3833Incomplete Surgery7/9/2020 3:36:43 PM
DispForm.aspx49385Rules / Policies / ProceduresImplementation of independent double checks during the preparation process for this high-alert medication and use of preprinted labels to be affixed to prepared bags are possible strategies to improve safety at the bedside.3822Errors Associated with Oxytocin Use: A Multi-Incident Analysis 7/9/2020 3:36:53 PM
DispForm.aspx49397Rules / Policies / ProceduresTo manufacturers: Add information about the interaction between PEG and starch-based thickeners to PEG laxative product monographs.3821Potentially Harmful Interaction between Polyethylene Glycol Laxative and Starch-Based Thickeners7/9/2020 3:36:55 PM
DispForm.aspx49429Rules / Policies / ProceduresEmphasize to personnel overseeing strategic planning and purchases for information technology that electronic systems housing patient medication data should ideally communicate seamlessly with each other, in real time, to support patient safety.3816Gaps in Interconnectivity of a Hospital’s Electronic Systems Create Vulnerabilities at Transitions of Care7/9/2020 3:37:00 PM
DispForm.aspx49442Rules / Policies / ProceduresDo not stock concentrated electrolytes in patient care areas.3815Preventable Tragedies: Two Pediatric Deaths Due to Intravenous Administration of Concentrated Electrolytes7/9/2020 3:37:01 PM
DispForm.aspx61093Rules / Policies / ProceduresEstablish a latex consultation service to help evaluate and manage latex allergic patients.3869Latex: A Lingering and Lurking Safety Risk7/9/2020 3:35:46 PM 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 PM 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 PM
DispForm.aspx61137Rules / Policies / ProceduresReview Sentinel Event Alert #57 ( along with this alert and commit to implementing a safety culture at your organization.3866Developing a reporting culture: Learning from close calls and hazardous conditions7/9/2020 3:35:54 PM
DispForm.aspx61144Rules / Policies / ProceduresClearly define workplace violence and put systems into place across the organization that enable staff to report workplace violence instances, including verbal abuse. - Leadership should establish a goal of zero harm to patients and staff - Emphasize the importance of reporting all events - Encourage conversations about workplace violence during daily unit huddles - Develop systems or tools to help staff identify the potential for violence - Develop a protocol, guidance and training about the reporting required by the hospital safety team, OSHA, police, and state authorities. - Create simple, trusted, and secure reporting systems that result in transparent outcomes, and are fully supported by leadership, management, and labor unions. - Remove all impediments to staff reporting incidents of violence toward workers3865Physical and verbal violence against health care workers7/9/2020 3:35:55 PM
DispForm.aspx61184Rules / Policies / ProceduresPrecautionary statements are included on dispensing labels of valproate indicating “This drug can harm fetus: Avoid pregnancy.” The statements are available in Chinese and English.3858Valproate - Risk minimisation measures in Hospital Authority7/22/2020 4:20:16 PM
DispForm.aspx61212Rules / Policies / ProceduresIdentify a clinical leader who will bring together key individuals from maternity, neonatal, paediatric and emergency care to plan the implementation of this alert.3852 Assessment and management of babies who are accidentally dropped in hospital7/9/2020 3:36:07 PM Management
DispForm.aspx91632Rules / 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.aspx91638Rules / 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.aspx91675Environment / 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.aspx91676Rules / 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.aspx91703Rules / 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.aspx91708Training"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.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.aspx91769Rules / 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.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.aspx91786Rules / 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.aspx91805Rules / 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.aspx91875Rules / 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.aspx91892Rules / 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.aspx91898Rules / Policies / ProceduresEnsure that current and complete allergy information, including descriptions of the reactions, is readily available to all prescribers when they are ordering medications.3667Prescribing Errors that Cause Harm2/11/2019 10:55:28 PM
DispForm.aspx91967Rules / Policies / ProceduresScreen patients for cognitive impairment.3663Health Literacy and Patient Safety Events2/11/2019 10:55:40 PM
DispForm.aspx91996Environment / 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.aspx92007Rules / 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.aspx92054TrainingEnsure 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.aspx92062Rules / 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.aspx92078Rules / 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