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Patient Safety Alert: Equipment Failure During Surgery and Replacement Parts896163457SurgeryUnited States of AmericaCalifornia Hospital Patient Safety OrganizationThis alert addresses the need to build resilience into hospital systems to prevent patient safety incidents related to the inaccessibility of spare surgical parts or tools while a procedure is in progress. In several cases reviewed by the California Hospital Patient Safety Organization, unique screwdrivers or drill bits have broken, or unique-size screws went missing. In at least one instance, the incision had to be temporarily closed with an implant partially secured and the patient was scheduled for re-operation to complete the procedure another day. “Resilience” is the capability to adaptively avert failures and rapidly respond to those that occur. Hospitals already have experience in developing resilience in specific areas, such as disaster response, but most organizations are not yet systematically applying resilience techniques to all applicable areas. Part of building resilience into a system is preparing in advance for problems, changes and hazards. The alert provides a detailed recommendation for preventing similar patient safety incidents.5/31/2017 7:20:45 PM6https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseSurgical Care Safety;Surgical Incidents
enFlow Fluid Warmers – Risk of Aluminium Toxicity4947538133/13/2019 6:00:00 AMMedical DeviceAustraliaNew South Wales Department of Health (Australia)This alert discusses the patient safety issues related to use of a warming device for intravenous infusion fluids which has an uncoated disposable aluminum heating plate. The heating plate can leak high concentrations of aluminium into intravenous infusion fluids. This could potentially lead to a risk of administering potentially harmful concentrations of aluminium when balanced salt crystalloid solutions (e.g. Hartmann’s and PlasmaLyte) are used. Clinical experts have advised that high aluminium levels may not be adequately excreted via renal system, and can have a long half-life if deposited in tissues. The true effects of aluminium toxicity is difficult to quantify; however, it is associated with a large range of diseases, including microcytic anaemia and encephalopathy. It is a clinical risk for patients to receive crystalloid fluids, blood or blood products via enFlow fluid warmers, or other fluid warmers with uncoated aluminium plates or cartridges to prevent hypothermia. If an alternative fluid warmer is not available, clinicians should undertake an individual patient risk assessment to establish a need for warming of parenteral fluids. Recommendations regarding the use of fluid warming devices to prevent hypothermia when administering parenteral fluids are provided.7/23/2020 3:11:28 AM3https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders8992535581/9/2018 7:00:00 AMOtherUnited KingdomNHS Commissioning BoardThis alert discusses the patient safety incidents that can occur when healthcare staff cannot deliver oxygen from cylinders to patients in a timely manner. The design of oxygen cylinders has changed over recent years. Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire valves must be closed when cylinders are not in use. Cylinders are often carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient. An unintended consequence of these changes is that staff may believe oxygen is flowing when it is not, and/or may be unable to turn the oxygen flow on in an emergency. Over a three year period, over 400 incidents involving incorrect operation of oxygen cylinder controls were reported. Six patients died, although most were already critically ill and may not have survived even if their oxygen supply had been maintained. Five patients had a respiratory and/or a cardiac arrest but were resuscitated, and four became unconscious. Incidents involved portable oxygen cylinders of all sizes on trolleys, wheelchairs, resuscitation trolleys and neonatal resuscitaires, and larger cylinders in hospital areas without piped oxygen. A typical incident was as follows: “Patient arrived on coronary care unit with oxygen saturations of 72%. Oxygen in situ and set to correct rate on the flow dial but unfortunately [the valve] was not opened and the patient was not therefore receiving oxygen. Peri-arrest on arrival, [crash team] called …..condition improved …..registered nurse continued to check cylinder was not running out but failed to notice not turned on as indicator green.” Recommendations to prevent similar incidents are provided.5/11/2020 2:19:03 AM3https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Oregon’s Top Patient Safety Lesson4888938998/26/2019 6:00:00 AMOtherUnited States of AmericaOregon Patient Safety Commission (USA)This alert identifies the critical need for a culture of safety before any patient safety quality improvements can have an effect. The relationship between a culture of safety and effective patient safety programs has also been present in recent patient safety research. One clear example of this relationship was noted in a recent study*, which found that the use of a quality measurement tool expressly designed to avoid blame was, in practice, experienced as a “blame allocation device.” Without a culture of safety, study participants could not use the tool to support their patient safety work, despite the intent and careful design of the tool. (*see https://www.sciencedirect.com/science/article/pii/S0277953617307773). Years of research and collaboration tell us that a culture of safety starts with engaging leadership support, establishing a system for reporting and analyzing adverse events, and dedicating the necessary resources to it. The alert recommends that facilities learn and implement the core elements for a culture of safety as outlined in the Patient Safety Reporting Program: 2018 Annual Report Oregon Patient Safety Commission.7/9/2020 3:34:46 PM4https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Ensure Safe Use of Smart Infusion Pumps4889838976/24/2019 6:00:00 AMMedical DeviceUnited States of AmericaOregon Patient Safety Commission (USA)This alert discusses the patient safety incidents which can occur with the use of smart infusion pumps. Healthcare facilities are increasing their reliance on smart infusion pumps to help reduce adverse drug events. However, smart infusion pumps don’t come without risk. In one new study of smart pumps, it was learned that delays in updating smart pump drug libraries pose a significant patient safety risk. When new drug library versions are released, significant delays can occur before all pump libraries are updated. The delays in drug library updates can lead to false alerts and missed infusions of high-risk medications. The alert provides a list of contributing factors to adverse events involving infusion pumps. In 2009, the Institute for Safe Medication Practices (ISMP) published its first Guidelines for Safe Implementation and Use of Smart Infusion Pumps. Now, a decade later, ISMP has drafted revised guidelines that will soon be finalized. Use of ISMP’s smart infusion pump guidelines is encouraged to ensure processes and practices maximize patient safety. The guidelines address implementation, clinical practice, and drug libraries. The alert provides some of the ISMP recommendations.7/23/2020 3:11:19 AM6https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Sling Loop Migration Causing Fall From Ceiling Track Lift4927238422/1/2019 7:00:00 AMFallsCanadaManitoba HealthThis patient safety learning advisory describes a patient safety incident of a fall of a resident during transfer using a ceiling track lift. The resident fell when the leg strap of the sling disconnected from the carry hook of the ceiling track lift. Staff attempted to catch the resident, but were only able to catch the legs, which resulted in the back of the resident’s head hitting the floor first. The resident sustained a laceration that required suturing. Contributing factors included the following: -Inconsistencies in the sequence of attaching the sling to the carry hook -Current ceiling track lift training videos utilize a different lift than the one being used during this fall. -The design of the carry hook and the folding arm allow for misconnections and accidents -Using a mechanical lift for transferring residents is complex and there are multiple steps to ensure safety. Recommendations to prevent similar incidents are provided.7/9/2020 3:36:18 PM6https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Lessons from a Coroner's case88961162/1/2012 7:00:00 AMCare ManagementAustraliaVictoria Department of Health (Australia)This alert describes a fatal patient safety incident where failure to diagnose a small bowel obstruction resulted in death. An elderly patient presented to the emergency department (ED) with abdominal pain and diarrhoea. The patient was treated conservatively by a junior doctor as abdominal X-ray showed no evidence of obstruction. The patient re-presented two days later with a similar problem and was again treated conservatively by a junior doctor. Subsequently, the patient complained of feeling unwell at home and collapsed on the way to hospital. Upon arrival at ED the patient had no heartbeat and resuscitation was unsuccessful. The cause of death was not apparent and the case was reported to the Coroner. The Coroner’s investigation found that death was caused by a small bowel obstruction. The Coroner commented that a review of medical management indicated that management was reasonable and appropriate. However, contributing factors were the following: - the absence of specific guidelines for managing abdominal pain in the elderly in ED, and - lack of escalation to more senior staff. The alert also referenced the Victorian Clinical Governance Policy Framework 2008 which provides a guide on clinical care governance for health service boards, chief executive offi cers, managers and clinicians, who are all ultimately accountable for the provision of safe quality health care. References for overview of abdominal pain in elderly patients and tools for recognizing and responding to clinical deterioration requiring escalation in care are provided.7/7/2015 8:47:46 AM3https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseGeneral Patient Safety;Patient Safety Incident
Two patients were unexpectedly hospitalized following procedures at ambulatory surgery centers8909714710/1/2010 6:00:00 AMSurgeryUnited States of AmericaNew Jersey Department of Health and Senior Services (USA)This alert describes two patient safety incidents related to lack of an of NPO (nothing by mouth) after surgery. Two patients were unexpectedly hospitalized following procedures at ambulatory surgery centers. One patient appropriate medical history and insufficient patient education on the meaning developed wheezing and stridor; the patient failed to mention a recent diagnosis of asthma and prescribed inhaler. The second patient vomited and aspirated immediately post-op; he had failed to follow the (NPO) no eating/drinking/ medication instructions prior to the procedure. It was determined that the cause of the incidents was a failure to identify important information related to the patients’ procedures. Some of the information should have been revealed during a thorough medical history and some should have been more effectively provided to the patient to ensure they understood their procedure and the care required thereafter. Two strategies for preventing this type of patient safety incident are provided.7/22/2015 5:50:32 PM3https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseSurgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist
Error Related to Lithium Dosage Conversion8967534014/1/2015 6:00:00 AMMedicationCanadaManitoba HealthThis alert describes a patient safety incident of drug overdose related to dose conversion of milligrams and mmol/mL of lithium carbonate, a drug with a narrow therapeutic index. A personal care home resident had been taking lithium carbonate (150mg capsule) twice daily for many years for bipolar disorder. After finding an elevated serum lithium level, a reduction in the lithium dose was required. Lithium carbonate is not available in a lower solid dosage form. As a result, lithium citrate syrup was dispensed to meet the prescribed dose. The resident received a medication dose that was 38 times the amount prescribed. The resident required transfer to the Intensive Care Unit for dialysis due to toxic levels of lithium. The resident recovered and was transferred back to the personal care home. The contributing factors included the following: • The discrepancy between the units ordered (mg) and the units supplied (mmol/mL) required a dose conversion. This conversion did not occur when dispensed by the pharmacy. • There were no maximum dose warnings generated by the pharmacy software. • The dose had been calculated at the pharmacy and printed on a label. The label had been affixed to the outside of the liium citrate bottle concealing information on the bottle. • Lithium ctrate is not considered to be a “High Alert” medication; independent double checks were not required. • The lthium ctrate bottle supplied was 500 mL. With the dose prescribed, there would be 217 doses in one bottle. Therefore, when the larger dose was dispensed at the time of medication administration, it was not noted to be a large amount taken from the bottle. Recommendations to prevent similar patient safety incidents of overdose related to dose conversion between two different units of measure are provided.5/31/2017 7:22:53 PM3https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseImproving Medication Safety;Medication Incident
Death Associated with an IV Compounding Error and Management of Care in a Naturopathic Centre9002937331/4/2018 7:00:00 AMMedicationCanadaInstitute for Safe Medication Practices CanadaThis Safety Bulletin describes a fatal patient safety incident involving a medication compounding error and inappropriate management of care in a naturopathic centre. A patient was discharged from hospital after surgical excision of a cancerous tumour and was further treated, in a collaborative arrangement, by a conventional medical team and a naturopathic doctor at a complementary care centre (CCC). The naturopathic doctor prescribed a complex tissue- and wound-healing formulation, which included selenium, for twice-weekly IV administration. The selenium solution was prepared by a compounding pharmacy and was added to the formulation on site at the CCC. The patient had received this healing formula on 12 previous occasions, with no reported reactions. However, shortly after initiation of the 13th dose infusion, she became nauseous and diaphoretic. The infusion was stopped, and homeopathic remedies were administered, with no clinical improvement. Over the next several hours, the patient’s condition continued to deteriorate. When the patient began to experience hypotension, shortness of breath to the point of cyanosis, and chest pain, she was transferred to the emergency department of a local hospital, where she later died. Postmortem investigations showed that the selenium concentration in the infusion was 1000 times greater than intended, which likely contributed to the patient’s death. Contributing factors identified included confirmation bias, use of the abbreviation “µg” instead of “mcg” for “micrograms”, and a visual check only for the weighed products instead of using a print out for each weighed product. Recommendations are provided for pharmacies (re: compounding processes), complementary care centre (re: emergency response processes and preparation, storage and administration of admixtures), and regulatory agencies.5/11/2020 3:44:59 AM6https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse