|Fall From Bed With Fracture||18088||3841||2/1/2019 7:00:00 AM||Falls||Canada||Manitoba Health||This patient safety learning advisory describes a patient safety incident of a fall from a bed resulting in a hip fracture. The resident had utilized bed rails to promote comfort, safety and positioning while in bed. A bed with a built in bed alarm was initiated due to resident’s attempts to get out of bed. It was learned that at the time of the fall the resident’s bed had been changed to one without a built in bed alarm. There was no documentation of when the beds were switched. In addition, the bed rail was down at the time of the fall. Inconsistent information in documentation contributed to resident specific falls interventions not being utilized and increased the likelihood of the fall.
Recommendations to prevent similar incidents are provided.||12/1/2021 2:38:58 PM||Gardes de lit, alarme de lit chute, fracture, stratégie pour la prévention des chutes, plan de soins, entretien ||6||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Hip Fracture related to a patient fall||17677||3526||10/1/2016 6:00:00 AM||Falls||Canada||Manitoba Health||This alert describes a patient safety incident of a fall by a client with a high risk for falls. The incident is described.
A senior patient, grabbed by a co-patient fell to the ground while attempting to release the co-patient’s grasp. Upon initial assessment, the patient sustained a small skin tear, but was able to get up with minimal assistance and no complaints of pain. Hours later, the patient began to complain of left hip discomfort. The patient was assessed by nursing staff to have no obvious injuries and given pain medication. Two days later, a written referral was completed for the medical doctor to assess the patient due to complaints of pain when asked. The patient was found to have a suspected hip fracture. The patient was taken to the local hospital where they were diagnosed with a fractured hip and underwent surgical repair.
Potential contributing factors are described:
- The patient had been assessed by the Occupational Therapist to be at high risk for falls. Despite this, the patient was resistant to utilize any recommended protective equipment.
- Nursing assessments and minimal complaints of pain did not result in an immediate assessment by the medical doctor.
System learnings are provided in the alert.||9/1/2017 8:54:12 PM||Fracture de la hanche, équipement de protection, précautions contre les chutes, prévention ||17||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Humeral Head Fracture ||17923||3804||10/1/2018 6:00:00 AM||Falls||Canada||Manitoba Health||This alert discusses a patient safety incident resulting in a humeral head fracture. The resident had a history of right sided weakness and dementia. The absence of a standardized mobility assessment tool increased the risk for incorrect type of mechanical lift used. A sit stand lift was utilized and was not the recommended lift for this client. Correct procedures for safe application of the sling were not utilized; the sling was positioned above the chest level rather than at the trunk level. Inconsistent safety practices when using the mechanical lift increased the risk of harm. The resident remained attached to the sling and mechanical lift and was left unattended on the toilet. Recommendations to prevent similar incidents are provided.||9/16/2019 8:23:23 PM||démence, évaluation de la mobilité, élingage, mauvais lève-personne mécanique, transfert ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Humeral Head Fracture ||17924||3803||10/1/2018 6:00:00 AM||Care Management||Canada||Manitoba Health||This alert discusses a patient safety incident resulting in a humeral head fracture. Concerns regarding the resident’s ability to transfer using a sit stand lift were raised after the incident. A regional policy supporting Safe Client Handling was in development. The existing policy was utilized which did not align with current training. This may have contributed to the use of an incorrect mechanical lift for the client’s needs. The resident was cognitively impaired, known to be aggressive and resist care. A behavioral/psychological assessment was not completed. There was a limited number of staff members who had completed the approved regional behavioral/psychological assessment training. Recommendations to prevent similar incidents are provided||9/16/2019 8:23:24 PM||mobilité, mauvais lève-personne mécanique, évaluation comportementale, déficience cognitive, démence, évaluation psychologique, transfert d'information, transition des soins ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Fall Resulting in Fracture||17958||3772||6/1/2017 6:00:00 AM||Falls||Canada||Manitoba Health||This alert briefly discusses a patient safety incident of a fall of a long term care resident resulting in a fractured pelvis. The resident’s care plan indicated a need for a pelvic restraint and a chair alarm. Neither was in place at the time of the fall. Implementation of the care plan would have reduced the likelihood of the fall and resulting fracture.
Contributing factors included suboptimal communication of the patient’s fall history between the sending facility and the long term care facility. Recommendations to prevent similar incidents are provided.||9/17/2019 3:59:46 PM||chair alarm, bed alarm, pelvic restraint alarme de chaise, alarme de lit, dispositif de bassin fracturé, antécédents de chutes, stratégies de réduction des chutes, routine de ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Fall Resulting in Fracture||17937||3791||6/1/2018 6:00:00 AM||Falls||Canada||Manitoba Health||This alert briefly describes a patient safety incident of a fall by a client who stumbled when rising in the night, resulting in a fractured femur. Contributing factors included lack of night lighting, deactivation of the bed alarm, lack of floor sensor pads and lack of documentation of a previous fall. Recommendations to prevent similar incidents are provided.||9/16/2019 8:23:35 PM||bed alarm,
floor sensor pads,
call bell éclairage, fémur fracturé, liste de vérification pour l'intervention en cas de chute, plan ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Unwitnessed Fall Resulting in Fracture||18090||3839||2/1/2019 7:00:00 AM||Falls||Canada||Manitoba Health||This patient safety learning advisory describes a patient safety incident of a fall of a hospitalized patient resulting in a fracture. A patient, recently discharged from hospital, presented to the emergency department multiple times with concerns over living conditions and the risk of falling at home. Patient was admitted to the hospital for observation with a diagnosis of failure to cope and query dementia. Patient experienced an unwitnessed fall resulting in a hip fracture (left femoral neck).
Contributing factors to the fall included the following:
- The fall risk assessment was not completed on admission as per policy.
- Documentation was not sufficient; the post fall documentation was missing from the health record and there was no documentation to support that the physician was made aware of fall.
A recommendation to prevent similar incidents is provided.||7/9/2020 3:36:38 PM||évaluation des risques de chute, fracture, démence ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Fall Resulting in Fracture||17946||3783||2/1/2018 7:00:00 AM||Falls||Canada||Manitoba Health||This alert describes a patient safety event of a fall of a resident in a long term care facility. The resident was ambulating through the dining area with a four-wheeled walker. The tables and chairs in the area were displaced to facilitate cleaning of the area. A feeding stool on wheels was moved out of the way by a staff member and inadvertently entered the path of the resident. The resident became agitated by approach of the oncoming stool, lost their balance and fell to the floor. The stool did not collide with the resident. The fall resulted in a fracture of the hip.
Contributing factors identified that the area had not been cordoned off to allow for cleaning and to restrict residents entering the area. The resident was wearing appropriate footwear. The Falls Prevention & Management Policy was utilized and falls prevention interventions were in place. A recommendation to prevent similar incidents is provided.||9/16/2019 8:23:46 PM||nettoyage du plancher, sécuriser, limiter l'accès, chaussures ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Fall Resulting in Fracture||17925||3802||10/1/2018 6:00:00 AM||Falls||Canada||Manitoba Health||This alert describes a patient safety incident of a fall related to equipment failure of a bed alarm. A personal care home resident fell, resulting in fractures of the seventh and eighth ribs as well as a fractured right femur. Staff initiated a bed alarm three weeks earlier following a fall. After this fall, the staff discovered that the bed alarm was not functioning and did not alert staff when the resident exited the bed. A review of the incident found that there was a lack of clarity about bed alarms, the indication for use, effectiveness, how to check batteries, when and how often to check alarms, and responsibility for preventative maintenance. Recommendations to prevent similar incidents are provided.||9/16/2019 8:23:25 PM||défaillance de l'équipement, batteries, entretien préventif, évaluation de la mobilité, défaillance de l'équipement ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Fall with Hip Fracture||17956||3774||6/1/2017 6:00:00 AM||Falls||Canada||Manitoba Health||This alert briefly describes a patient safety incident of a fall. The client was standing in the bathroom with a staff member. When the staff member moved away from the client, the client moved unexpectedly and fell to the floor. The fall resulted in a fractured hip.
Contributing factors included lack of documentation on the resident’s care plan that a two-person assist was necessary to reduce the risk of a fall due the resident’s limited mobility. Recommendations to prevent similar incidents are provided.||9/17/2019 3:59:43 PM||chutes, équipe multidisciplinaire, prévention globale des chutes, évaluation de la mobilité, stratégies de prévention des chutes, aide à deux personnes, gestion des chutes ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|