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Reducing treatment dose errors with low molecular weight heparins17535NPSA0587/30/2010 6:00:00 AMMedicationEngland and WalesNational Health Service Commissioning Board (England and Wales)This Rapid Response Report addresses dosing errors that can lead to patient harm through an overdose or underdose. Contributing factors to these type of patient safety incidents include: - not weighing patients prior to dosing, - estimating body weight, - recording body weight inaccurately, - miscalculation of doses based on a patient’s weight, - the prescribed, dispensed or administered dose and frequency of low molecular weight heparins (LMWH) were outside accepted guidelines for the required clinical indication and other predisposing conditions such as renal failure; and - limited patient information (i.e. weight, dosage, indication and intended duration of treatment) communicated at transfers of care. Actions to prevent risk of occurrence are provided.7/7/2015 9:22:44 AM4 Safety;Medication Incident;Patient Safety Incident
Safer administration of insulin17539NPSA0636/16/2010 6:00:00 AMMedicationEngland and WalesNational Health Service Commissioning Board (England and Wales)This Rapid Response Report discusses patient safety incidents associated with the use of insulin, frequently resulting in administering the wrong dose. Factors contributing to these incidents include the following: - the inappropriate use of non-insulin (IV) syringes, which are marked in mL and not in insulin units, - the use of abbreviations such as ‘U’ or ‘IU’ for units. When abbreviations are added to the intended dose, the dose may be misread, e.g. 10U is read as 100, and - insufficient training in the use of insulin by healthcare professionals. Actions to reduce risk of occurrence are provided.7/7/2015 9:22:44 AM6 Safety;Medication Incident;Patient Safety Incident
Lessons from a Coroner's case17596162/1/2012 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 AM3 Patient Safety;Patient Safety Incident
Enema Tubing Illusion17660815/10/2012 6:00:00 AMMedical DeviceUnited States of AmericaOregon Patient Safety Commission (USA)This alert discusses a patient safety incident of a retained foreign body following a procedure and resulting from misunderstanding of how to use equipment. The design of the equipment was identified as a contributing factor. The long blue cap on the tubing of an enema kit has a scoop-shaped end with an indented edge. To the staff member using the kit to give the patient an enema, this edge appeared to have an opening. In giving the enema, the blue cap was retained in the patient, causing some discomfort and constipation. After a multi-day colon preparation, the patient eliminated the cap. Recommendations to prevent similar patient safety incidents are provided.5/11/2020 2:15:56 AM9 Safety Incident
Burst Birthing/ Exercise Ball Near Miss17661825/10/2012 6:00:00 AMObstetrics & GynecologyUnited States of AmericaOregon Patient Safety Commission (USA)This alert addresses patient safety incidents that can occur with equipment that has not been examined for wear and replacement. A laboring patient recently experienced the collapse of her birthing ball. The ball collapsed and although startled, neither the patient nor baby suffered any harm. Physical therapy and rehabilitation patients also use these types of balls as do some yoga instructors and office workers. The hospital discovered that the ball had been in use for many years and was concerned about the effect of cleaning agents on the integrity of the ball. Recommendations to prevent similar patient safety incidents are provided.5/11/2020 2:15:56 AM10 Associated Conditions;Patient Safety Incident
Infusion Pumps: Preventing Future Adverse Events17686JC2311/1/2000 7:00:00 AMMedical DeviceUnited States of AmericaThe Joint Commission (USA)"Mishaps involving the use of infusion pumps have led to deaths and near-fatal drug overdoses. The main problem is with the use of pumps that do not provide protection from the free-flow of intravenous fluid/medication into the patient. Causes of these incidents include: human error, staffing patterns, work pressures, having many different concentrations of critical care drugs, and lack of standards. Many errors could be prevented if organizations only use infusion pumps that require set-based free-flow protection. This alert describes actions to reduce risk."5/11/2020 2:12:09 AM4 Safety Incident
Two patients were unexpectedly hospitalized following procedures at ambulatory surgery centers1772914710/1/2010 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 PM6 Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist
Amiodarone maintenance was infused at 210ml/hr instead of 21ml/hr177611784/1/2012 6:00:00 AMMedicationHong KongHong Kong Hospital AuthorityThis alert describes a patient safety incident where a patient received a wrong dose of a high alert drug due to an error in programming an infusion pump. A patient who was in shock and tachycardia was given a loading dose of IV Amiodarone 150mg in 100mL D5, to be followed by a maintenance dose of 600mg in 500mL D5 over 24 hours (at 21mL/hour). However, the maintenance infusion was completed in 3 hours and it was found that the infusion rate was wrongly set at 210mL/hour instead of 21mL/hour. Contributing factors included: 1. Mistook the presence of a decimal point before the “0” on rate display (ie. 21.0 versus 210 mL/hour). 2. Lack of independent double-checking of pump settings before commencing the infusion. 3. No regular monitoring of infused amount / volume after commencement. Recommendations to prevent similar patient safety incidents are provided.7/7/2015 9:17:43 AM3 Safety;Medication Incident;Patient Safety Incident
Blood Transfusion Error in Victoria State Australia177631804/1/2012 6:00:00 AMCare ManagementHong KongHong Kong Hospital AuthorityThis alert is a reprinted article of a patient safety incident where a patient received the wrong blood. A patient undergoing an elective surgical wound debridement began to bleed, requiring urgent administration of O negative blood. A unit of O negative blood intended for another patient in the operation theatre arrived. A nurse collected the blood and thought it was for the patient undergoing the elective wound debridement. The blood was not checked prior to administration in accordance with hospital procedure and the wrong blood was administered. Fortunately, both patients required the same blood type and no adverse outcome occurred. Recommendations to prevent similar patient safety incidents are provided.5/11/2020 2:16:09 AM3 Associated Conditions;Patient Safety Incident
Medical Device Alarm Safety in Hospitals1783830824/8/2013 6:00:00 AMMedical DeviceUnited States of AmericaThe Joint Commission (USA)This alert addresses patient safety incidents that can occur when medical devices with alarm systems are not appropriately responded to because of "alarm fatigue". Medical devices which have alarm systems include bedside physiologic monitors that include ECG (electrocardiogram) machines, pulse oximetry devices, blood pressure and other parameters monitoring devices, bedside telemetry; central station monitors; infusion pumps and ventilators. These alarm-equipped medical devices are essential to providing safe care to patients in many health care settings but patient safety incidents can occur when when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.5/11/2020 2:16:28 AM5 Safety Incident