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Preventing infant death and injury during delivery16982JC147/1/2004 6:00:00 AMCare ManagementUnited States of AmericaThe Joint Commission (USA)"The overall goal for labour and delivery units is for a healthy and safe birth for the mother and infant. However, there have been patient safety incidents reported where tragedy occurs and the newborn dies. Contributing factors related to perinatal mortality include absence of early and regular prenatal care for the mother, maternal age, previous cesarean section, diabetes, substance abuse, non-reassuring fetal status, placental abruption, ruptured uterus, and breech presentation. This Sentinel Event Alert provides information about identified root causes as well as actions to reduce risk in perinatal mortality."7/7/2015 8:47:40 AMÉvénements liés à la gestion des soins 6https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseGeneral Patient Safety;Patient Safety Incident
Maternal Death or Serious Morbidity Associated with Labour and Delivery. Case 1: Maternal Death with Primary Postpartum Haemorrhage and Genital Tract Trauma1710714010/1/2012 6:00:00 AMHong KongHong Kong Hospital AuthorityThis alert descibes a fatal patient safety incident occurring immediately postpartum. Soon after normal vaginal delivery, a patient developed postpartum bleeding and a cervical tear was suspected by the attending midwife. The on-call medical officer, a resident specialist, and an associate consultant were called for assistance. To manage the persistent oozing and massive blood loss, a total of three operations were performed. Despite all treatment, the patient's condition deteriorated and the patient died. A contributing factor was that the occurrence of a retroperitoneal haematoma was rare and it was difficult to diagnose.10/14/2021 12:49:16 PMaccouchement vaginal, saignements post-partum, déchirement cervical, perte de sang, hémorétropéritoine 9https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Maternal Death or Serious Morbidity Associated with Labour and Delivery. Case 2: Serious Morbidity Associated with Delivery1710814110/1/2012 6:00:00 AMObstetrics & GynecologyHong KongHong Kong Hospital AuthorityThis alert describes a patient safety incident involving a high risk pregnancy. A patient who underwent emergency lower segment Cesarean section for threatened preterm labour and small preterm twins delivered two healthy babies. Soon after delivery, the patient complained of headache. Her blood pressure was noted to be high. No proteinuria was detected. The patient was given 2 bolus injections of an antihypertensive drug after which the headache improved and blood pressure returned to normal. Two hours later, the patient’s conscious level deteriorated; she developed up-rolling eyeball and was noted to have hypertension. Her CT brain revealed acute intracranial haemorrhage. The patient underwent an emergency neurosurgical operation followed by rehabilitation care.5/11/2020 2:16:04 AMcésarienne, travail avant terme, chirurgie, hypertension, hémorragie intracrânienne, grossesse à risque, urgence obstétrique, supervision https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseProcedure Associated Conditions;Patient Safety Incident
Serious morbidity associated with labour and delivery18614VIC0513/1/2010 7:00:00 AMObstetrics & GynecologyAustraliaVictoria Department of Health (Australia)"A patient presented to emergency (ED) in early labour, no other medical history was given by the patient or her partner. Fetal heart monitoring noted three broad decelerations in the fetal heart rate and transfer to the labour ward was initiated. The ED midwife verbally handed over to the labour midwife including the decelerations. The resident reviewed the fetal monitoring and advised continued monitoring. Further prolonged decelerations occurred, the registrar attended and the patient was booked for an emergency caesearean section. The baby was born with apgars of 0 at 5 and 0 at 10 minutes and active resuscitation was unsuccessful. The anaesthetist noticed that the mother had an abnormal heart rhythm and the consultant noticed an abnormal glucose tolerance test and pregnancy induced thyrotoxicosis. When the medical record was reviewed it was noticed that the women had attended a pregnancy diabetes clinic and was on insulin. A blood sugar was immediately performed and the mother was assessed to have diabetic ketoacidosis. The mother required an insulin infusion and a three day stay in the high dependency unit. A delay in access to important relevant clinical information was identified as the primary care delivery problem. This alert describes actions to reduce risk."5/11/2020 2:14:36 AMserious disability associated with labour or delivery in a low-risk pregnancy while being Décès ou grave invalidité de la mère associé(e) au travail ou à l'accouchement pour une https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseProcedure Associated Conditions;Patient Safety Incident
Variability in oxygen delivery with bag valve masks 1818639852/15/2021 7:00:00 AMDeviceAustraliaNew South Wales Department of Health (Australia)This Safety Notice discusses the potential patient safety incidents posed by various bag valve masks (BVMs) in the delivery of inspired oxygen. Different BVMs may provide different fractions of inspired oxygen concentration (FiO2). A BVM is a hand-held device used to provide positive pressure ventilation. It is also used for preoxygenation of spontaneously breathing patients before intubation to extend the safe apnoea time during intubation or in situations where 100% inspired oxygen is required for spontaneously breathing patients. There are BVMs in use without a valve to prevent air entrainment during spontaneous ventilation. This anti air-entrainment valve is located in the expiratory pathway and can vary between models. The absence of this valve (also called expiratory or flow diverter valve) for spontaneously breathing patients allows room air to mix with 100% oxygen from the reservoir. This can reduce the inspired oxygen concentration to less than 65%. Some BVMs have a positive end-expiratory pressure (PEEP) valve already attached and set to the ‘on’ position at up to 10cmH2O. If a BVM with that level of PEEP were placed on a child/adult in respiratory distress it could cause significant harm. Some BVMs do not have over-pressure release valves increasing the risk of high inspiratory pressures and barotrauma. The notice provides criteria for selecting BMVs and recommended actions to prevent relevant patient safety incidents. 11/30/2021 10:00:19 PMexpiratory valve, flow diverter valve, resuscitation trolleys, anaesthetic trolleys, positive end-expiratory pressure (PEEP) valve, over-pressure release valve https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Medtronic SynchroMed EL Implantable Pump - Neurological drug delivery pumps17840NSW139/1/2007 6:00:00 AMMedical DeviceAustraliaNew South Wales Department of Health (Australia)"Patient safety incidents have occurred where the motor of an implantable pump stalls which results in a loss of pain management, chemotherapy or baclofen therapy for patients. The pump does not provide an alarm to alert a patient or clinician that the motor has stalled."5/11/2020 2:12:30 AMPatient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalsePatient Safety Incident
Omission of High-Alert Medications: A Hidden Danger17473335512/1/2014 7:00:00 AMMedicationUnited States of AmericaPennsylvania Patient Safety Authority (USA)This alert discusses the incidence of drug omissions which occur with high-alert medications, the contributing factors, the type of medications frequently involved, where in the medication use process these incidents occurred and risk reduction strategies to prevent related patient safety incidents. A drug omission can be defined as an event in which an appropriate medication is not provided to a patient, either because the medication has not been prescribed or has not been administered. The impact of a drug omission varies from insignificant to severe harm, depending on the medications and the patient’s medical conditions. The alert provides case examples illustrating the omission errors during administration, transcription and prescribing. Risk reduction strategies re provided aaddressing the use of technology, transcribing and communicating orders, and the IV administration of high-alert drugs.9/9/2015 11:16:13 AMpumps, IV tubing, Add-Vantage™ delivery system, patient-controlled analgesia pump (PCA adrenergic agonists, IV, antithrombotic agents (anticoagulants), chemotherapeutic agents https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Preventing Maternal Death17126JC281/1/2010 7:00:00 AMObstetrics & GynecologyUnited States of AmericaThe Joint Commission (USA)"Current trends and evidence suggest that maternal mortality rates (deaths that occur within 42 days of birth or termination of pregnancy) may be increasing in the U.S. The leading causes of maternal death are: hemorrhage, hypertensive disorder, pulmonary embolism, amniotic fluid embolism, infection and pre-existing chronic conditions. The most common preventable errors are: failure to adequately control blood pressure, failure to adequately diagnose and treat pulmonary edema, failure to pay attention to vital signs following Cesarean section, and hemmorhage following Cesarean section. This alert describes actions to reduce risk."5/11/2020 2:12:13 AMserious disability associated with labour or delivery in a low-risk pregnancy while being Décès ou grave invalidité de la mère associé(e) au travail ou à l'accouchement pour une https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseProcedure Associated Conditions;Patient Safety Incident
Preventing maternal death18284HK0185/1/2010 6:00:00 AMObstetrics & GynecologyHong KongHong Kong Hospital AuthorityMaternal mortality rates may be on the increase in the United States and studies have shown that 28 to 50 percent of these deaths were preventable. The most common preventable maternal deaths were identified. This alert includes actions to reduce risk.5/11/2020 2:11:56 AMserious disability associated with labour or delivery in a low-risk pregnancy while being Décès ou grave invalidité de la mère associé(e) au travail ou à l'accouchement pour une https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseProcedure Associated Conditions;Patient Safety Incident
Pathology Testing - Caesarean Section Operations17962NSW246/1/2010 6:00:00 AMObstetrics & GynecologyAustraliaNew South Wales Department of Health (Australia)"Patient safety incidents may occur as a result of significant blood loss during Caesarean section. In this case, a patient died from multi-system organ failure following a postpartum haemorrhage after a caesearean operation. Practice with respect to routine full blood count and group and hold for patients having caesearean section operations varies across sectors. This alert includes actions to reduce risk."5/11/2020 2:12:38 AMserious disability associated with labour or delivery in a low-risk pregnancy while being Décès ou grave invalidité de la mère associé(e) au travail ou à l'accouchement pour une https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseProcedure Associated Conditions;Patient Safety Incident