|Clean hands save lives||19675||NPSA038||9/2/2008 6:00:00 AM||Infection Prevention and Control||England and Wales||National Health Service Commissioning Board (England and Wales)||Significant gains have been made in highlighting the need for best practice in hand hygiene. This Patient Safety Alert highlights the continuing vigilance for proper hand hygiene of healthcare staff during patient care to reduce healthcare associated infections. Hands are a repository for microorganisms that can cause infection and healthcare staff in all healthcare settings have a great chance of transferring these as they move between patients, or different care activities for the same patient. Key points to remember are included in the Alert such as: the role of hand hygiene by healthcare staff in preventing and controlling infection, the point of care as the crucial moment for hand hygiene, the appropriate placement of alcohol handrub products, which hand hygiene products to use and when, the current recognised standard for hand hygiene products, and management of risks including ingestion, storage and skin irritation. Actions to reduce risk have also been included in the Alert. ||5/11/2020 9:15:27 AM||prévention de l'infection, lavage des mains ||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Infection Prevention ＆ Control;Healthcare Associated Infections;Hand Hygiene;Patient Safety Incident|
|Two patients were unexpectedly hospitalized following procedures at ambulatory surgery centers||17729||147||10/1/2010 6:00:00 AM||Surgery||United States of America||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||postop, postopératoire, post-chirurgie, antécédents médicaux, éducation des patients, évaluation préadmission, questions ciblées, consignes RVO, rien par voie orale, aucune ||6||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist|
|Distractions in the Operating Room||17958||3226||6/1/2014 6:00:00 AM||Surgery||United States of America||Pennsylvania Patient Safety Authority (USA)||This alert discusses the patient safety incidents that can occur in the operating room due to distractions and/or interruptions related to human communication, equipment such as surgical alarms or technology (e.g. phone calls, pagers).
Distraction is a threat to patient safety in the operating room (OR). Analysis of events reported through the Pennsylvania Patient Safety Reporting System from January 2010 through May 2013 revealed 304 reports of events occurring in the OR in which distractions and/or interruptions were indicated as contributing factors. Attention is warranted to all events impacted by distraction in the OR regardless of frequency, due to their high potential to result in serious patient harm. Distraction is particularly detrimental to performance of complex tasks that require higher levels of cognitive processing, such as those frequently encountered in the OR.
With regard to case-irrelevant communications (CICs), defined as communication not relevant to the surgical procedure in progress. Half of all CICs consisted of “small talk.” Although surgeons initiated and received the greatest number of CICs, visitors to the OR (defined as external staff not belonging to the OR team involved in the current surgical procedure) initiated CICs with the highest levels of observable distraction (i.e., causing team members to pause, disrupting workflow). Communications directed to nurses and anesthesia providers resulted in higher levels of distraction than communications directed to surgeons.
Distraction from computers and personal electronic devices (PEDs) is also a growing concern for OR teams. The widespread use of computers in clinical settings, along with the recent rapid growth in the use of cell phones and smartphones, has contributed to a heightened focus on the potential for error and harm caused by distractions that result from the use of these devices, particularly within the OR environment. “Distracted doctoring” is a term coined by the media to describe this phenomenon. Distraction from smartphones and other mobile devices was identified as one of the top 10 health technology hazards for 2013 by ECRI Institute.
The following are examples of Serious Events (i.e., events involving patient harm) reported and
associated with distraction in the OR:
—— Wrong-side surgery
—— Wrong-site surgery
—— Transfusion of the wrong blood to the wrong patient
—— Failure to remove a piece of resected bowel, requiring a return to the OR
—— Injection of a patient using an unlabeled syringe and needle previously used on another patient
—— Failure to notice a significant loss of evoked potential from a patient’s arm during spinal surgery
—— Inflation of a tourniquet applied to a patient’s leg for longer than intended, resulting in neurovascular changes
Studies examining the impact of distraction in the OR setting, along with guidelines and tools developed by perioperative professional associations and patient safety agencies to limit and/or ameliorate the negative impact of distraction are discussed (e.g., application of the “sterile cockpit” concept from aviation, reducing distractions from technology and noise, use of surgical safety checklists and briefings, teamwork training). Engagement of surgeons and multidisciplinary teams is necessary to address the problem of distractions in the OR.||7/22/2015 5:51:59 PM||surgical equipment alarms, smart alarms, beepers, pagers, cell phones, smartphones, needles, sponges, tourniquet alarme de matériel chirurgical, alarmes intelligentes ||3||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist|
|Be Antibiotics Aware: Protect Your Patients||18747||4034||11/9/2021 7:00:00 AM||Medication||United States of America||Oregon Patient Safety Commission (USA)||This alert addresses the need for responsible prescribing of antibiotics to fight antibiotic resistance and prevent the spread of superbugs. During U.S. Antibiotic Awareness Week and throughout the year, Centre for Disease Control (CDC) promotes Be Antibiotics Aware, an educational effort to raise awareness about the importance of safe antibiotic prescribing and use. The Be Antibiotics Aware initiative provides resources to help improve antibiotic prescribing among healthcare professionals and use among consumers. The alert provides numerous recommendations on responsible antibiotic prescribing. ||3/1/2022 7:22:05 PM||directives cliniques, dose, durée, infection virale, C. difficile, septicémie, cultures hygiène des mains, prévention des infections, effets secondaires, réactions allergiques ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Retained Paraffin Gauze in Tracheostomy Wound||18114||3330||10/1/2014 6:00:00 AM||Surgery||Hong Kong||Hong Kong Hospital Authority||This alert describes a patient safety incident of a retained foreign body in a patient following an emergency tracheostomy.
Following the tracheostomy, Doctor A documented in the operation record “packed with sulfatulle (paraffin) X 2”. On post-operation day 2, a nurse followed the post-operative order and removed a piece of paraffin gauze covered with copious sputum. On post-operation day 6, an ENT (ear, nose, throat) team was consulted for wound discharge from the patient’s tracheostomy. An ENT surgeon spotted and subsequently removed 1 piece of paraffin gauze which was left inside the tracheostomy wound. The patient did not suffer any adverse outcome.
Contributing factors to this incident included the following:
1. No proper counting of paraffin gauze after removal of packing.
2. Complex patient condition hindered wound inspection process; the patient had a short neck, a relatively large tracheostomy wound, and firm anchoring stitches for the new tracheostomy.
Recommendations to prevent similar patient safety incidents are provided.
||5/31/2017 7:29:52 PM||pansement, comptage chirurgical, gaze, écoulement de la plaie, infection ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Retained Gauze in Abdomen Wound||18115||3329||10/1/2014 6:00:00 AM||Surgery||Hong Kong||Hong Kong Hospital Authority||This alert describes a patient safety incident of a retained foreign body in a patient following surgery for closure of a colostomy.
During the operation, there was wound contamination and a “Lasso knot” with 3 loose stitches was applied with the aim of having closure of the skin later by tightening the stitches on the ward. The patient’s wound was packed with 1 piece of plain non-woven gauze which was then covered with plain gauzes. On post-operation day 1, the case doctor performed wound dressing and documented “changed dressing and gauze removed”. On post-operation day 2, another doctor closed the wound by tightening the loose stitches and ordered daily wound dressing. On post-operation day 13, stitches were removed because of increasing exudate from the wound. During wound exploration, a piece of plain non-woven gauze was found and removed from the patient’s wound. The patient’s wound healed well.
The contributing factors to the incident included the following:
1. Small size gauze was used for packing into a relatively big wound.
2. The non-woven plain gauze was not easily identified after being soaked with blood and exudate.
3. Misinterpretation of the “dressing” gauze as the “packed” gauze.
Recommendations to prevent similar patient safety incidents are provided.
||5/31/2017 7:29:53 PM||de plaie, colostomie, noeud Lasso, contamination, infection, exsudat, comptage chirurgical ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Pre-Pouring Medications||18076||3366||3/26/2015 6:00:00 AM||Medication||Canada||Alberta Health Services||This alert discusses the potential patient safety incidents of pre-pouring medications before they are ready to be administered to the patient.
Pre-pouring medications can contribute to medication errors because of the following:
1. The medications cannot accurately be compared to those on the Medication Administration Record once they are removed from their labelled package; and
2. Pre-pouring violates at least two of the seven rights of medication administration (right patient & right medication).
Recommended actions are provided to mitigate the risk of patient safety incidents in administering medications.||7/7/2015 9:20:40 AM||moment, fréquence, voie d'administration, infection nosocomiale, contrôle des infections ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Medication Safety;Medication Incident;Patient Safety Incident|
|Robotic-Assisted Surgery: Focus on Training and Credentialing||18094||3349||9/1/2014 6:00:00 AM||Surgery||United States of America||Pennsylvania Patient Safety Authority (USA)||This alert discusses the introduction of robotic-assisted surgery (RAS) and its impact on patient safety incidents and effective surgical outcomes. The use of robotic technology has escalated over the past four years, and the number of robotic-assisted surgeries (RASs) performed worldwide nearly tripled between 2007 and 2010.
The alert contains recommendations for the safe implementation and credentialing of robotic-assisted radical prostatectomies at an institution published by the Society of Urologic Robotic Surgeons. These are included in the “Recommendations” section of this alert.||5/31/2017 7:29:30 PM||da Vinci® Surgical System,
metallic clip perforation, corps étranger retenu, infection, perte de sang, compétence, éducation ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Blood control safety cannula & needle thoracostomy for tension pneumothorax||18862||3941||4/2/2020 6:00:00 AM||Device||United Kingdom||NHS Commissioning Board||This alert addresses the patient safety incidents which may occur when the wrong devices are used to treat tension pneumothorax. Tension pneumothorax is a life-threatening condition resulting from a collapsed lung when air trapped in the pleural cavity compromises cardiopulmonary function. Immediate temporary decompression is required to prevent cardiac arrest. This is commonly done by inserting a needle and cannula, usually used for intravenous access, through the chest wall into the pleural cavity. The needle is withdrawn, and the cannula left in place to allow the trapped air to flow out. New blood control (closed system) intravenous cannulas look very similar to both traditional and standard safety cannula (with needle guard or shield) but have an extra integral septum which closes when the needle is withdrawn and stops free flow in or out of the cannula. Blood control (closed system) cannulas help prevent blood spillage, exposure and contamination, when used for their intended intravenous purpose, but they cannot be used to decompress a pneumothorax without additional equipment. Several actions are recommended to safely treat tension pneumothorax and prevent adverse events.||2/14/2022 5:38:51 PM||blood control (closed system) intravenous cannulas, needle, safety cannula, Luer-lok syringe respiratoire, maladie respiratoire, infection, réanimation, ventilation, poumon collabé ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Automatic Endoscope Reprocessors||18167||NJ07||6/1/2009 6:00:00 AM||Medical Device||United States of America||New 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 AM||"Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility Décès ou grave invalidité d'un patient ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Patient Safety Incident|