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Foreign body aspiration during intubation, advanced airway management or ventilation1886039449/1/2020 6:00:00 AMDeviceCanadaNHS Commissioning BoardThis alert discusses the patient safety incidence of aspiration of a foreign body during intubation, advanced airway management or ventilation. Loose items unintentionally introduced into the airway during intubation, ventilation or advanced airway management (known as foreign body aspiration [FBA]) can lead to partial or complete airway blockage or obstruction. If the cause is not suspected, this can be fatal. Complications following FBA may not be immediately recognised due to sedation and anaesthesia and may be postoperatively misdiagnosed as asthma, chronic obstructive pulmonary disease (COPD), or stridor. In a recent six-year period, five incidents were identified where a foreign body (FB) was aspirated, and a further four incidents where the FB was identified during intubation and removed. The most common types of FB identified in incident reports were transparent backing plastic from electrocardiogram (ECG) electrodes and plastic caps of unclear origin. This is likely to be an under-estimate of the true number of incidents as many may go unrecognised. Contributing factors are provided in the alert along with recommended actions to prevent related foreign body aspiration.2/14/2022 5:38:47 PMECG/ECT electrodes, airway trays, breathing system hoses, resuscitation trolley, emergency response kits, bespoke caps, HME filter soins de courte durée, soins intensifs, soins https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Interruption of high flow nasal oxygen during transfer1886339401/4/2020 7:00:00 AMMedical GasUnited KingdomNHS Commissioning BoardThis alert addresses the actual and potential patient safety incidents that occur when high flow nasal oxygen is interrupted. Specialised equipment is used to deliver high flow nasal oxygen (HFNO) to babies, children and adults in acute respiratory failure without hypercapnia. Current national guidance states that HFNO is not advocated in COVID-19 patients based on lack of efficacy, oxygen use and infection spread. Some HFNO delivery devices have a transport mode, but most require main power and will not deliver oxygen during transfer unless attached to a compatible uninterruptible power supply (UPS) device. Four deaths were reported in a recent two-year period from interrupted HFNO during patient transfer; further reports described hypoxia, cyanosis, collapse and respiratory arrest. Several contributing factors are listed in the alert. Actions to mitigate the immediate risk from inadvertent interruption of HFNO are provided.2/14/2022 5:38:53 PMuninterruptible power supply (UPS) , battery, reservoir mask, oxygen cylinder hypercapnie, mode «transport», COVID-19, hypoxie, cyanose, collapsus, intubation https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Drug Shortages: Shortchanging Quality and Safe Patient Care18925407212/1/2021 7:00:00 AMMedicationUnited States of AmericaPennsylvania Patient Safety Authority (USA)This article addresses the patient and medication safety incidents that can occur during a drug shortage. A total of 448 medication error event reports associated with drug shortages were submitted to the Pennsylvania Patient Safety Authority from July 2004 through June 2018. Nearly three-quarters (71.0%) of events reached the patient. Drug shortage reports involved 173 individual drugs, representing 57 different drug classes, with the most commonly reported drugs being analgesics, followed by antibiotics, electrolytes, and antidotes (e.g., reversal and rescue agents). High alert medications were involved in nearly one-half (46.2%) of reports. The total number of reports was distributed evenly among the prescribing, dispensing, and administering nodes of the medication use system. This article identifies the reasons these events took place, discusses the use of best practices, and provides system-based risk reduction strategies and recommendations.2/25/2022 10:02:34 PMagents de secours, agents d’intubation à séquence rapide), immunoglobuline intraveineuse rescue agents, rapid sequence intubation agents), intravenous immune globulin (IVIG https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
OPSC Review of Maternal and Perinatal Events 18915418210/20/2021 6:00:00 AMObstetrics/ Labour and DeliveryUnited States of AmericaOregon Patient Safety Commission (USA)This alert discusses the findings of the Oregon Patient Safety Commission (OPSC) of a review of adverse event reports involving a mother, fetus, and/or neonate during the period of 2012 to 2020. The alert provides finding of event frequency by year, most frequent event types, harm categories (71% resulted in serious harm or death), patient demographics and place where events occurred. Root and proximal causes are provided in detail. Many of the adverse events involved care delays, including failure to recognize a mother or baby’s changing condition during a long labor, a misinterpretation of or lack of communication about questionable fetal heart tracings, and a breakdown of communication between providers and staff both within and across units, specifically in emergent situations.2/25/2022 9:36:22 PMBakri balloon, sponges, vaginal packing, echocardiograph, epidural supplies, infusion pump dotation inadéquate, arrondissement, allaitement, intubation, réanimation, faible poids à https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Insufficient patient monitoring after sedative medication18890408812/12/2018 7:00:00 AMMedicationSouth KoreaKorea Patient Safety Reporting & Learning SystemThis alert addresses the need for effective patient monitoring following administration of sedative medication. Two fatal cases are described where patients received sedative medications, midazolam and ketamine, and propofol, respectively. The alert provides detailed recommendations on preventing adverse events in sedated patients examining periods of pre-sedation, during sedation, post-sedation, medical equipment required and training for medical staff and other healthcare providers. In addition, 2 cases illustrating the care required for a pediatric and adult are provided. Included, as well, are guidelines for the use of sedatives in children and adolescents and guidelines for the use of sedatives in adults. 2/14/2022 7:47:54 PMgloves, alcohol wipes, sterile gauze pads, intravenous catheters(24-22gauge), intravenous vitaux, voies respiratoires, ventilation, intubation, pouls, saturation en oxygène, dosage https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Neuromuscular Blocking Agents-Minimising Risk19624NSW05311/22/2011 7:00:00 AMMedicationAustraliaNew South Wales Department of Health (Australia)This safety alert highlights the absolute requirement for appropriate airway support whenever neuromuscular blocking agents (high alert drugs) are administered. Inappropriate use of neuromuscular blocking agents can lead to catastrophic injury or death. New South Wales Health received notice of cases where neuromuscular blocking agents had been used to achieve muscle relaxation without the availability of appropriate airway support leading to death. The majority of incidents have involved clinical errors caused by: - Look alike packaging and labelling. - Sound alike medicine names. - Drug administration after extubation. - Use of pre-prepared unlabelled syringes. - Unsafe storage, particularly small quantities in refrigerators. - Use in areas where clinical staff may be unfamiliar with the drugs and their action.7/7/2015 9:22:41 AMpatients hospitalisés (soins intensifs, unités de médecine / chirurgie), urgence, radiologie voies respiratoires, ventilation mécanique, intubation trachéale, extubation, emballage https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseMedication Safety;Medication Incident;Patient Safety Incident
Propofol 2% (20 mg/mL): Safety Considerations for Introducing a Novel Product into Hospitals1884439245/29/2020 6:00:00 AMMedicationCanadaInstitute for Safe Medication Practices CanadaThis alert addresses the potential patient safety incidents with the introduction of a double-strength propofol (2%) made necessary by the shortage of the 1% product. Propofol is a short-acting general anesthetic / sedative approved in Canada for sedation during intensive care and other procedures, as well as for induction and maintenance of general anesthesia. The demand for propofol is exceeding supply during the pandemic. The temporary importation of propofol 2% from Europe is intended to fill the need of the shortage of the 1% product, but its introduction to the Canadian market carries certain risks. Not only is the 2% product double the strength of the 1% product familiar to Canadian practitioners, but it is also not currently supported by medication systems, including infusion pump drug libraries. A 2-fold overdose of propofol can result in hemodynamic instability, cardiovascular collapse, and death. The safety bulletin provides numerous recommendations to reduce the likelihood of medication errors involving the use of propofol, both 1% and 2%.2/14/2022 5:39:17 PMsoins de courte durée, soins intensifs, salle d’opération, médecine, médicament, soins de médicaments, alerte élevée, intubation, surdose, mauvaise dose, facteurs humains https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Letter to the Editor: Propofol Administration19093PA0779/1/2006 6:00:00 AMMedicationUnited States of AmericaPennsylvania Patient Safety Authority (USA)"This letter to the editor addresses a previous Patient Safety Advisory report describing how problems can occur during propofol (a high alert drug) administration and to provide strategies to prevent future problems. The letter discusses safe use of propofol in the emergency department for short procedures. Response to the letter describes two patient safety incidents that occurred with the use of propofol. Contributing factors that may lead to patient safety incidents with propofol include lack of complete drug information for staff, inadequate staff training/mentoring before propofol is used, unavailability of qualified staff not involved in the procedure to continuously monitor the patient, and lapses in monitoring when the patient is transported from the unit or ED to radiology"7/7/2015 9:22:38 AM"Patient death or serious disability associated with a medication error (e.g., errors de la dislocation de l'épaule, intubation à séquence rapide, demi-vie, service d'urgence https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseMedication Safety;Medication Incident;Patient Safety Incident
Topical Anaesthetic–Induced Methemoglobinemia19148PA1353/1/2005 7:00:00 AMMedicationUnited States of AmericaPennsylvania Patient Safety Authority (USA)"This Patient Safety Advisory discusses patient safety incidents where patients develop methemoglobinemia as a result of the use of topical anaesthetics. Contributing factors for the development of methemoglobinemia include the following: - using multiple sprays of agents like benzocaine, - spraying the area for a longer duration than recommended, - clinicians may be unfamiliar with the significant absorption of topical anesthetics, so they may not realize how much medication they are giving patients when using the sprays. - patients also could self-administer topical anesthetics in doses that exceed manufacturers’ recommendations. Several patient safety incidents are described and recommendations to mitigate risk of occurrence are provided."7/7/2015 9:22:40 AM"Patient death or serious disability associated with a medication error (e.g., errors "endoscopie, bronchoscopie, intubation, inhalé, en vente libre, EVL, topique, étiquette https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseMedication Safety;Medication Incident;Patient Safety Incident
Drug Shortages: Shortchanging Quality and Safe Patient Care1865338863/1/2019 7:00:00 AMMedicationUnited States of AmericaPennsylvania Patient Safety Authority (USA)This alert discusses the patient safety incidents that occur when drug shortages are experienced. Pennsylvania Patient Safety Authority analysts reviewed medication errors associated with drug shortages submitted through PA-PSRS from July 2004 through June 2018 and in this report identify the reasons these events took place, discuss the use of best practices, and provide system-based risk reduction strategies and recommendations. A total of 448 medication error event reports associated with drug shortages were submitted to the Pennsylvania Patient Safety Authority from July 2004 through June 2018. Nearly three-quarters (71.0%) of events reached the patient. Drug shortage reports involved 173 individual drugs, representing 57 different drug classes, with the most commonly reported drugs being analgesics, followed by antibiotics, electrolytes, and antidotes (e.g., reversal and rescue agents). Medications that pose an increased risk of patient harm when involved in medication errors, also known as high-alert medications, were involved in nearly one-half (46.2%) of reports. The most common high-alert drug classes included opioid analgesics, injectable benzodiazepines, and parenteral electrolyte supplements (e.g., potassium chloride, sodium bicarbonate). The year with the greatest number of submitted reports was 2012 (16.5%), with the most frequently cited medication shortage in 2012 involving the opioid analgesic nalbuphine (25.7%). In 2017, the most commonly reported medication shortage involved morphine (13.4%).The total number of reports was distributed evenly among the prescribing, dispensing, and administering nodes of the medication use system. High levels of frustration and tension among providers facing shortages that lack clearly defined or communicated management strategies are apparent from the reports. Organizations may use the data in this article and the revised Drug Shortage Assessment Checklist to inform proactive efforts, standardize protocols in drug shortage situations, prevent similar errors from occurring, and strengthen our national culture of safety. Specific risk reduction strategies are provided.7/9/2020 3:34:51 PMautomated dispensing cabinets (ADCs), drug box, prefilled syringes antidotes, reversal agents, rapid sequence intubation agents, rescue agents, dextrose 50 https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse