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DispForm.aspx1501CommunicationPost results of the audits monitoring compliance with the Surgical Safety Checklist for shared learning.3792Wrong Site Surgery9/16/2019 8:23:35 PM3
DispForm.aspx1533CommunicationReport Aesculap cautery tip defect to Heath Canada.3788Foreign Body Left in Client9/16/2019 8:23:39 PM
DispForm.aspx1534CommunicationProvide patients with appropriate communication when awaiting the booking of followup appointments. Provide direction to patients to contact their health care providers within a specific time frame if they have not heard anything back regarding pending appointments/tests.3775Delay in Diagnosis/Treatment Summary9/17/2019 3:59:43 PM
DispForm.aspx1554CommunicationInform patients of their need to participate in ensuring that their care is safe and what they need to do to stay safe.3786Unwitnessed fall9/16/2019 8:23:43 PM
DispForm.aspx1745CommunicationShare the lessons learned from this patient safety event with the Department of Emergency Medicine and site Chief Medical Officers so they may share with their respective staff.3784Medication Error - Missed Dose of Neupogen9/16/2019 8:23:45 PM
DispForm.aspx1752CommunicationDevelop a structured communication method for physicians to alert nursing staff when new orders are written on the Emergency/Outpatient Record.3782Delayed Diagnosis of Abdominal Pain 9/16/2019 8:23:47 PM
DispForm.aspx1765CommunicationEstablish communication vehicles (monthly teleconferences and a SharePoint page) to highlight new program information.3780Gaps in Wound Care Services in Home Care Environment 9/16/2019 8:23:49 PM
DispForm.aspx1775CommunicationReport the event to the Institute for Safe Medication Practices (ISMP) Canada to share learning with respect to sound alike names and the potential for adverse medication events.3778Medication Adverse Event9/16/2019 8:23:51 PM
DispForm.aspx1815CommunicationDiscuss this event at unit meeting for shared learning and require the involvement of management to facilitate room assignments when changes are required.3769Incorrect Surgical Site9/17/2019 3:59:49 PM
DispForm.aspx1821CommunicationPromote enhanced interdisciplinary team communication by documenting client specific wound prevention interventions in client health record care plans. This would enhance continuity of best practice care and treatment. Follow up to monitor care plan implementation.3768Stage 3-4 Pressure Injuries in Long Term Care Residents9/17/2019 3:59:51 PM
DispForm.aspx1831CommunicationIdentify and communicate expectations regarding methods of client handover and communication between surgeons.3766Deterioration in Patient Condition Related to Incorrect Kaofeed Tube Placement9/17/2019 3:59:53 PM
DispForm.aspx1848CommunicationPost information cards at oxygen storage tank locations.3763Failure to Provide High Flow Oxygen during Intra-facility Transfer9/17/2019 3:59:56 PM
DispForm.aspx1862CommunicationFeel free to ask questions about any of your loved one’s medications at any time. This is especially important if your family member was recently in the hospital, as changes may have been made during the hospital stay.3761Medication Reviews in Long-Term Care Homes9/17/2019 4:00:00 PM
DispForm.aspx1865CommunicationTalk to a healthcare provider about how to use your insulin pen. Ask the provider to show you how to use the pen. Also ask for step-by-step written instructions, to be sure that you don’t miss any details of the process.3760Insulin Pens: Important Safety Information9/17/2019 4:00:01 PM
DispForm.aspx1881CommunicationAsk your pharmacist to explain what the extension in your medication name means. If you know the meaning, it may be easier to remember the full name of your medication.3757Brand Name Extension: What Does It Mean? 9/17/2019 4:00:04 PM
DispForm.aspx1898CommunicationSome medications from home may be stopped while you are in the hospital, or the doses may be changed. Don’t be afraid to asknyour healthcare provider to explain any medication changes.3755Using Your Own Medications While in Hospital 9/17/2019 4:00:07 PM3
DispForm.aspx1901CommunicationWhen you get a prescription from your doctor, ask when the medication needs to be started.3754Do NOT Delay Starting Certain Medications9/17/2019 4:00:08 PM
DispForm.aspx1906CommunicationTalk to a pharmacist or another healthcare provider before using a medication to treat a new symptom. Ask whether the new symptom could be caused by any of your current medications.3753New Symptoms: Could They Be Related to Your Medications?9/17/2019 4:00:09 PM3
DispForm.aspx1915CommunicationEven if you feel a bit embarrassed, take a deep breath and talk to your healthcare provider about all of your medications, including those for sensitive health problems. This can help you get the best possible care.3752Don’t Be Embarrassed to Talk to Your Pharmacist 9/17/2019 4:00:10 PM
DispForm.aspx1918CommunicationIf your doctor prescribes an opioid medication, be sure to ask about the risks. For example, ask whether you or a loved one is at high risk of an opioid overdose.3751Save a Life—Get a Naloxone Kit to Treat an Opioid Overdose9/17/2019 4:00:11 PM
DispForm.aspx1930CommunicationWhen picking up a new medication from the pharmacy, set aside time to talk to the pharmacist about your prescription. If you are not offered counselling, ask to speak with the pharmacist.3749Talking to Your Pharmacist May Prevent Harm 9/17/2019 4:00:13 PM
DispForm.aspx1943CommunicationLet all your healthcare providers know if you have any allergies to medications. This is very important when a new medication is being started, because it may be similar to the medication that you are allergic to.3748Do You Know Your Medication Allergies? 9/17/2019 4:00:16 PM
DispForm.aspx1957CommunicationRemember that medications may have different names in different countries. If you are unsure about anything related to your medications, ask a healthcare provider for advice.3746Losing Medications Can Spoil Your Vacation 9/17/2019 4:00:18 PM
DispForm.aspx1962CommunicationFor children less than 12 years old, expect healthcare providers to weigh your child at every visit. All other children should expect to be weighed every year. Be sure to tell your healthcare provider about any weight changes, including normal growth and development.3745Know and Share Your Weight in Kilograms 9/17/2019 4:00:39 PM
DispForm.aspx1965CommunicationWhen you and your healthcare provider agree that a medication can be stopped, ask how it should be stopped. Ask your healthcare provider for written instructions, especially if the dose changes are frequent and complicated.3744Suddenly Stopping a Medication Can Be Harmful 9/17/2019 4:00:40 PM
DispForm.aspx1969CommunicationIf you experience a new symptom or a sudden change in your health, ask your doctor if one or more of the medications you are already taking may be the cause.3743Some Medications Don’t Mix 9/17/2019 4:00:40 PM
DispForm.aspx2003CommunicationTo eliminate confusion among patients as they arrive at the clinic, post information about patient intake and consent procedures.3739Injecting Standardization into Vaccine Clinics9/17/2019 4:00:46 PM
DispForm.aspx2024CommunicationFor community practitioners, in cases of medications with a high risk for toxic effects, inform patients about the symptoms indicating toxicity and how to manage these situations (e.g., call the poison control centre, administer naloxone) if they arise. When feasible, consider proactively supplying patients with an antidote (e.g., naloxone kit) if there is a concern for toxicity.3738Antidotes and Related Agents: Recognition of Need, Availability, and Effective Use9/17/2019 4:00:49 PM
DispForm.aspx2035CommunicationEngage in conversation with patients about the safe storage of medications in the home and about the safe disposal of unnecessary or expired medications.3737Safe Storage and Disposal of Medications9/17/2019 4:00:51 PM
DispForm.aspx2075CommunicationPharmacies: Question patient requests to purchase products used primarily or exclusively for compounding. Ask for the indication or reason for use and involve the pharmacist.3732Alert: Polyethylene Glycol and Propylene Glycol Mix-up Causes Harm9/17/2019 4:01:00 PM
DispForm.aspx2086CommunicationFor the Second Victim Healthcare Practitioner: Share your story. Most second victims welcome conversations with colleagues about their experience. Retelling the event to a peer who has had a similar experience can be a powerful tool in the healing process. Sharing stories with a supportive colleague who is not judgmental and who does not lay blame can give the second victim insight and reassurance.10 Reporting the adverse event to ISMP Canada through the Individual Practitioner Reporting program ( can facilitate widespread learning from one person’s experience.3731The Second Victim: Sharing the Journey toward Healing9/17/2019 4:01:02 PM
DispForm.aspx2490CommunicationStaff - report any events involving ceiling lifts into the Reporting and Learning System and notify Facilities Maintenance & Engineering or Clinical Engineering, fill out Product Feedback Form as appropriate.3810Handicare/Prism Medical C series Ceiling Lift -Potential of Sling Straps Not Remaining on Carry Bar2/6/2020 8:38:29 AM
DispForm.aspx2499CommunicationManagers: consult with local Clinical Engineering to discuss options for setting the alarm default configuration based on individual site needs.3809Alarm Default Settings-LIFEPAK Monitor/Defibrillator11/7/2019 5:47:15 PM
DispForm.aspx49508Communication"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.aspx49519CommunicationPrior 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.aspx49521Communication"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 AM3
DispForm.aspx49539CommunicationEngage 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.aspx49543CommunicationClear 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 AM3
DispForm.aspx49573CommunicationNotify most responsible physician/ nurse practitioner.3720Timely response and follow-up after patient exposure to blood and bodily fluids2/11/2019 10:53:34 PM
DispForm.aspx49592Communication"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.aspx49598CommunicationCreate 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.aspx49603Communication"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.aspx49609Communication"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.aspx49632Communication"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.aspx49635CommunicationProvide 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
DispForm.aspx49644Communication"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.aspx49652Communication"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.aspx49661CommunicationEngage family members whenever they express concerns about their child’s behaviour—subtle changes may be more readily identified as abnormal by family members than by healthcare providers and thus can provide an invaluable source of assessment information.ISMPC45Hospital-Acquired Hyponatremia: Two Reports of Paediatric Deaths6/4/2015 2:11:07 AM
DispForm.aspx49662CommunicationObjective parameters for measuring pain poster operatively are important and allow for a smooth transition when a change in pain management occurs from postanesthesia to oral analgesia in home care. PA139Unanticipated Care After Discharge from Ambulatory Surgical Facilities6/4/2015 2:11:07 AM
DispForm.aspx49694CommunicationThe Facility Director (or designee) will ensure that all Dialysis staff and Biomedical Engineering staff are made aware of this Patient Safety Alert. VA55Possible blood contamination in hemodialysis machines6/4/2015 2:11:08 AM