|"AEDPlus Public Access Automated External Defibrillators (AEDs), manufactured by Zoll."||90378||VA47||3/1/2009 7:00:00 AM||Medical Device||National Center for Patient Safety (Department of Veteran's Affairs - USA)||"The affected defibrillators’ batteries can have a shorter than expected life, expiring after three years, rather than five. When used in defibrillation, the device may verbally prompt users to “change batteries” and fail to deliver therapy. There will be no prior warning of the failure. This alert affects all AEDPlus defibrillators sold before March 2009. The AEDPlus is distributed in many areas, both clinical and administrative. Additionally, they are distributed to VA in general, including VACO, VBA, VCA and OI&T offices. The Alert describes actions to be implemented by applicable VA facilities. "||5/11/2020 2:14:14 AM||6||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Oregon’s Top Patient Safety Lesson||48889||3899||8/26/2019 6:00:00 AM||Other||Oregon 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 PM||4||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Ensure Safe Use of Smart Infusion Pumps||48898||3897||6/24/2019 6:00:00 AM||Medical Device||Oregon 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 AM||6||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Sling Loop Migration Causing Fall From Ceiling Track Lift||49272||3842||2/1/2019 7:00:00 AM||Falls||Manitoba Health||This 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 PM||6||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Two patients were unexpectedly hospitalized following procedures at ambulatory surgery centers||89097||147||10/1/2010 6:00:00 AM||Surgery||New 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 PM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Death Associated with an IV Compounding Error and Management of Care in a Naturopathic Centre||90029||3733||1/4/2018 7:00:00 AM||Medication||Institute for Safe Medication Practices Canada||This 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 AM||6||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|You Can Make a Difference: Help Prevent Medication Shortages||48543||3907||4/28/2020 6:00:00 AM||COVID-19||Institute for Safe Medication Practices Canada||This newsletter discusses the current situation regarding dispensing of prescription medication for a 30 day supply only to prevent drug shortages across the country during the COVID-19 pandemic. Several consumers have expressed concern about not getting more than a 30 day supply of their medications thinking that the rationale for limits is due to a drug shortage. The newsletter explains this process is in place to prevent a drug shortage and provides suggestions on how consumers can do their part to get through the pandemic and ensure there is enough medication for everyone.||6/15/2020 4:00:07 PM||4||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Virtual Medication History Interviews and Discharge Education||60939||3903||4/7/2020 6:00:00 AM||COVID-19||Institute for Safe Medication Practices Canada||This Safety Bulletin addresses the need for use of novel technology to obtain a medication history and to provide patient education during times when direct patient contact is non-advisable for the safety of both the patient and health care provider. Such a time is during the COVID-19 pandemic. ISMP Canada recommends that medication history interviews and discharge patient education be conducted by telephone, video communication, or email, with the dual goals of reducing the number of non-essential entries into patients’ rooms (and the associated risk of viral transmission) and conserving personal protective equipment (PPE) during a pandemic. The Bulletin provides numerous recommendations to provide virtual medication histories and provide discharge medication. A fax template for communicating with the community pharmacy is provided. Additional recommendations, available via the references, are provided by the New Brunswick Branch of the Canadian Society of Hospital Pharmacists.||7/22/2020 4:17:40 PM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Protecting Canadians from Unsafe Drugs Act What It Means for You||49331||3830||8/21/2019 6:00:00 AM||Medication||Institute for Safe Medication Practices Canada||This newsletter discusses new legislation in Canada that requires mandatory reporting of serious drug adverse events and medical device incidents to Health Canada. The legislation, “Protecting Canadians from Unsafe Drugs Act”, also known as “Vanessa’s Law” empowers individuals to report patient safety incidents or to request that the healthcare provider do so. With reported information, Health Canada will be better able to:
• require manufacturers to make changes to health product labelling or packaging to make safety information more available to everyone;
• take action when a serious risk to health is identified (for example, by removing unsafe drugs and medical devices from the Canadian market); and
• improve product safety for all Canadians.
The newsletter provides several suggestions for consumers to be engaged in reporting adverse events related to drugs or medical devices. These suggestions are available in the recommendations section of this alert.||7/9/2020 3:36:45 PM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Depleted batteries in intraosseous injectors||61205||3853||11/5/2019 7:00:00 AM||Medical Device||NHS Commissioning Board||This alert discusses the patient safety incidents which may occur when a device used to access the blood supply through the intraosseous route is not working due to a depleted battery charge. The intraosseous (IO) route (that is, through the bone marrow) is used to access the venous system when intravenous access is not possible, often in emergency situations, including cardiopulmonary resuscitation. IO access is most commonly achieved using a battery-powered injector. As the battery is sealed within the device and cannot be recharged or replaced, the first sign a battery may be depleted is in some circumstances when it does not work.
This alert asks providers to replace any battery-powered IO devices that do not have a battery power indicator light with ones with a display that shows how much power is remaining. Where IO devices with a battery power indicator are used, providers are asked to take steps to embed regular checks of these devices to ensure sufficient battery power remains so the devices are always ready and available. Specific actions are provided in the alert.||7/23/2020 3:11:25 AM||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|