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Potentially Contaminated Medication17666865/10/2012 6:00:00 AMMedicationUnited States of AmericaOregon Patient Safety Commission (USA)This alert addresses serious and fatal patient safety incidents resulting from use of a potentially contaminated medication. The Centers for Disease Control and Prevention (CDC) released a Health Advisory via the Health Alert Network for a potentially contaminated medication- an epidural steroid injection- resulting in fungal meningitis. Several of the infected patients suffered strokes which were believed to be related to the infection and five deaths were reported as of October 4, 2012. While the investigation into the exact source is ongoing, preliminary information indicates all infected patients received injections containing preservative-free methylprednisolone acetate (80mg/ml) prepared by New England Compounding Center, in Framingham, MA. Actions taken by the compounding centre and actions to be taken by healthcare professionals are provided.7/7/2015 9:20:34 AMcontaminé, contamination, méningite fongique, accident vasculaire cérébral, New England Compounding Center, sans agent de conservation, épidural https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseMedication Safety;Medication Incident;Patient Safety Incident
Contaminated lung biopsy1850435641/1/2016 7:00:00 AMInfection Prevention and ControlHong KongHong Kong Hospital AuthorityThis alert describes a patient safety incident of a wrong diagnosis which led to an unnecessary surgical procedure. Two patients had Computed Tomography (CT scan) guided lung biopsy performed on the same morning. Pathology reports confirmed both patients had the same type of lung cancer. On subsequent assessment, one patient was referred to the Department of Cardiothoracic Surgery in another hospital for further management. The patient had surgical removal of the right lower lung lobe. Pathological examination of the excised lung tissue revealed features of tuberculous infection instead of lung cancer. It was found that contamination of the patient specimen led to the wrong diagnosis. Factors that may have contributed to the contamination of the specimen included laboratory procedures used in biopsy collection, tissue wrapping, and embedding. Recommendations to prevent similar incidents are provided.5/11/2020 2:19:02 AMFlacon à échantillon, bouteille de rinçage Tomodensitométrie, tomodensitométrie informatisée, tuberculose, cancer du poumon, diagnostic erroné, prélèvement de biopsie, emballage du https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Infection from contaminated ultrasound gel1853235385/12/2017 6:00:00 AMInfection Prevention and ControlAustraliaNew South Wales Department of Health (Australia)This alert discusses the life threatening infections (eight reported to date) associated with ultrasound gel contaminated with Burkholderia cenocepacia. Burkholderia cenocepacia is a species of Gram-negative bacteria that is common in the environment, can form a biofilm with itself, and is resistant to many antibiotics. The gel is supplied in a kit with a sheath for ultrasound use and is used for insertion of central venous catheters (CVC) or peripherally inserted central catheters (PICC). The gel product is labelled as sterile. The kit is supplied by Meditech Systems Limited, manufactured by Linmed Medical. The gel is labelled Medical Ultrasound Gel. It is possible that the same gel is included in other ultrasound probe kits. An investigation was ongoing at the time of release of this alert, and alerts regarding other products may have been issued. Recommendations to address the possibility of infections caused by use of this contaminated gel, actions to remove this product from all stock, and need for reporting of any infections caused by Burkholderia cenocepacia are provided. 5/11/2020 2:19:08 AMcentral venous catheters (CVC), peripherally inserted central catheters (PICC cathéters veineux centraux (CVC), cathéters centraux à insertion périphérique (CCIP https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Contaminated pathology specimen resulting in an unnecessary procedure19403VIC0461/1/2010 7:00:00 AMMedical DeviceAustraliaVictoria Department of Health (Australia)A patient was referred to oncology following pathology results indicative of a poorly differentiated carcinoma. The patient underwent radical surgery and the pathology results indicated that there was no tumour and clinical doubt was raised about the original pathology results. Pathology undertook an investigation which suggested the possibility that another patient's specimen was present in the slides and DNA testing confirmed that the tumour cells had a different DNA profile than Patient A. The contaminant was subsequently found to be from another patient (Patient B) whose specimen was processed immediately prior to Patient A's specimen. Patient B received the correct treatment. Patient A was informed of the incident. It was not possible to ascertain the exact point of contamination. This alert describes actions to reduce risk.5/11/2020 2:14:34 AMassociated with the use of contaminated drugs, devices, or biologics provided by the Décès ou grave invalidité d'un patient par suite de l'utilisation d'appareils ou de produits https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalsePatient Safety Incident
Automatic Endoscope Reprocessors18167NJ076/1/2009 6:00:00 AMMedical DeviceUnited States of AmericaNew Jersey Department of Health and Senior Services (USA)"During an evaluation of medical equipment in the endoscope unit, two areas of concern were noted with near-miss patient safety incidents. It was discovered that the cycle used to disinfect equipment was significantly shorter than the manufacturer's suggested time plus staff were unable to determine if optimal temperatures for proper disinfection of equipment was reached during the disinfection process, as only a light indicated temperatures but no gauges for more accuracy. A break down of the evaluation findings revealed several pertinent issues: improper initial set-up of the equipment by the manufacturer, lack of adequate staff training on interpreting and understanding the computer printouts, no instruction manual available for the equipment users and no visual temperature gauge. Further actions to reduce risk have been included in this alert."5/11/2020 2:12:21 AMassociated with the use of contaminated drugs, devices, or biologics provided by the Décès ou grave invalidité d'un patient par suite de l'utilisation d'appareils ou de produits https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalsePatient Safety Incident
Threat of Cornea Transplant Contamination19144PA1326/1/2006 6:00:00 AMMedical DeviceUnited States of AmericaPennsylvania Patient Safety Authority (USA)"A patient developed endophalmitis one day after a corneal transplant. The patient was treated by a retinal specialist and did well. Two months later, the patient developed a lesion on the cornea and required corneal biopsy and cultures. This case and other reported cases bring to light the inherent risks associated with any transplant. Patients, staff, physicians and organizations must have confidence that the organ or tissue is safe for implantation. The JCAHO Provision of Care standards (effective July 5, 2005) with emphasis on acquiring, receiving, storing and issuing tissue, are presented in detail."5/11/2020 2:13:04 AMassociated with the use of contaminated drugs, devices, or biologics provided by the Décès ou grave invalidité d'un patient par suite de l'utilisation d'appareils ou de produits https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalsePatient Safety Incident
Potential for Error – failure to sterilise instruments19402VIC0453/1/2006 7:00:00 AMMedical DeviceAustraliaVictoria Department of Health (Australia)"During the second last procedure on the operating list, the instruments failed. A second set of instruments were opened and the procedure completed. Both sets of instruments were sent to central sterilising for reprocessing. The last patient on the operating list was having a similar procedure that required the same instrumentation. Staff retrieved a complete set of instruments, manually cleaned them and 'flash' sterilized them. A second staff member removed the instruments and did not notice that the steriliser had not functioned properly and the unsterilised instruments were used on the patient. A number of incidents involving the incorrect use of and documentation associated with 'flash' sterilisers. The major contributing factors to this incident were inappropriate use of the 'flash' steriliser, failure of the documentation/notification processes, staff unfamiliar with sterilisation procedures and equipment, lack of documented responsibilities for staff in relation to instrument sterilisation, and unplanned instrument requirements. This alert describes actions to reduce risk. "5/11/2020 2:14:34 AMassociated with the use of contaminated drugs, devices, or biologics provided by the Décès ou grave invalidité d'un patient par suite de l'utilisation d'appareils ou de produits https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalsePatient Safety Incident
Continuity of Oxygen Therapy During Intrahospital Transport19058PA0389/1/2005 6:00:00 AMOtherUnited States of AmericaPennsylvania Patient Safety Authority (USA)"Four incidents are described where patients were compromised when their supplemental oxygen supply was interrupted during transportation to/from another department. In the first incident, the patient's pulse oximeter alarmed and the oxygen saturation was 85% while being transported from therapy. The oxygen canister was turned off. In the second incident, the patient's oxygen saturation was 70% on arrival in the operating room. The oxygen cylinder was empty. In the third incident, the patient had a decrease in oxygen saturation while waiting for in-line oxygen therapy in radiology. In the last incident, the patient was being mechanically ventilated and when placed on the ventilator, appeared to be "bucking the vent." Although the oxygen tube was connected, it was not turned on. There are multiple steps and equipment connections in oxygen therapy and each step holds the potential for failure including: failure to treat with oxygen when ordered, failure to initiate flow from the oxygen source, failure to connect the oxygen tubing to the oxygen source, failure to place the oxygen delivery device on the patient, and failure to anticipate oxygen demand throughout patient transportation and to provide an adequate supply. This alert describes actions to reduce risk. "5/11/2020 2:12:49 AMto be delivered to a patient contains the wrong gas or is contaminated by toxic substances "Tout événement impliquant une ligne d'oxygène ou d'autre gaz fourni à un patient, qui https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalsePatient Safety Incident
“It’s in the blood” - A neglected cause of transfusion-fever19399VIC04311/1/2003 7:00:00 AMMedical DeviceAustraliaVictoria Department of Health (Australia)This Risk Watch article concerns two patient safety incidents involving the bacterial contamination of platelet bags used for transfusion. Both patients developed high fevers during the transfusion with one of those patients also developing chest tightness and severe abdominal cramping. Both patients made a full recovery. This article provides answers to important questions regarding bacterial contamination and provides additional resources for more information.5/11/2020 2:14:33 AMassociated with the use of contaminated drugs, devices, or biologics provided by the Décès ou grave invalidité d'un patient par suite de l'utilisation d'appareils ou de produits https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalsePatient Safety Incident
Methicillin-resistant Staphylococcus aureus (MRSA) contamination in an orthopaedic clinic room19327VA3810/1/2008 6:00:00 AMInfection Prevention and ControlUnited States of AmericaNational Center for Patient Safety (Department of Veteran's Affairs - USA)"Several patients who received joint/bursa injections in one orthopedic surgery clinic exam room, during a four-day period, developed infections. For those patients who had cultures grown, MRSA was identified as the causative agent. Infections may have been caused by improper preparation of injections, cross contamination between multidose vials and/or breach of appropriate practices following the collection of a specimen for microbiological culture from a patient who was infected with MRSA. During the investigation issues related to documentation were also identified. The Advisory describes recommendations for implementation in applicable VA facilities. "5/11/2020 2:14:07 AMassociated with the use of contaminated drugs, devices, or biologics provided by the "orthopédie, chirurgie, consultations externes, services aux hospitalisés, soins ambulatoires https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseInfection Prevention ＆ Control;Healthcare Associated Infections;Hand Hygiene;Patient Safety Incident