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Incorrect Blood Transfusion to a Newborn17247HK00411/1/2008 6:00:00 AMCare ManagementHong KongHong Kong Hospital Authority"This Risk Alert concerns a patient safety incident where a newborn received the wrong blood type transfusion even after the correct type was properly documented in the Laboratory Information System. Due to an environmental distraction, incorrect blood type was issued and administered by the staff. The infant did not experience any harm from this incident. It was noted that no automatic alert system is build in for the Blood Bank Laboratory Information System for similar scenarios, the clinical departments were not aware of the Type and Screen Guidelines of the facility and the technologist was distracted at the time of issuing the blood request. Key actions to reduce risk are provided and the key learning points are to always read the patient information and screening results. Staff also need to be made fully aware of guidelines related to blood transfusion and neonates."5/11/2020 2:11:43 AMPatient death or serious disability associated with a haemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseProcedure Associated Conditions;Patient Safety Incident
Low temperature as a sign of sepsis in newborn babies18934NPSA02310/29/2010 6:00:00 AMCare ManagementEngland and WalesNational Health Service Commissioning Board (England and Wales)This Signal outlines risks to neonates where failure to recognize that an inability to maintain body temperature may be a sign of sepsis. A fatal patient safety incident occurred after the delivery of a 37 week neonate. Post delivery, the mother became unwell and developed a fever. The infant was noted to have trouble maintaining his body temperature and died as a result of septicemia. The inability to maintain his temperature had not been recognized as a potential sign of infection. Signs of early-onset sepsis in newborn babies are often vague and therefore a greater level of vigilance is required to ensure the monitoring of infants who are identified as having a higher risk of developing neonatal sepsis. Common themes identified in patient safety reports included environmental issues that lead the infant to getting cold, failure to review an infant, delay in checking temperature or prescribing antibiotics and failure to document prolonged ruptured membranes. See complete alert for more details. 7/7/2015 8:58:41 AMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseGeneral Patient Safety;Patient Safety Incident
Balancing Family Bonding with Newborn Safety1747833509/1/2014 6:00:00 AMPediatricUnited States of AmericaPennsylvania Patient Safety Authority (USA)This alert discusses the patient safety incidents of newborn accidental injuries in the care of family members soon after a hospital birth. Hospitals face a challenge to support bonding of newborns with their families by encouraging breastfeeding, cuddling, holding, and touching while ensuring newborn safety. Analysis of reports submitted to the Pennsylvania Patient Safety Authority from July 2004 to 2013 showed there were 288 newborn events. Risk reduction strategies are shared in the alert and focus on implementing a falls prevention intervention, providing a safe sleeping environment, providing education for families on newborn safety that includes falls, and implementing a postfall huddle to examine why the fall occurred and what could be done to prevent future falls. Several of the strategies are included in the “Recommendations” section of this alert. 5/11/2020 2:17:11 AMnarcotics/opiates, IV, transdermal, and oral chutes, allaitement, fatigue, chute, choc, sans réaction, sensibilisation de la famille, éducation, indicateur de chute, incubateur https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Retained Consumables and Instruments - Catheter Tip Cut and Retained in Newborn's Intestine1738331914/1/2014 6:00:00 AMCare ManagementHong KongHong Kong Hospital AuthorityThis alert discusses a patient safety incident of retention of a foreign body following an invasive procedure. The specific incident is described. A premature newborn developed respiratory distress after birth and was intubated. Surfactant treatment was given via a multi-access catheter designed for accessing the airway. After endobronchial administration of the surfactant, the case doctor retracted the catheter from the endotracheal tube (ETT). Residue surfactant inside the catheter was observed and so the catheter was re-inserted into the ETT and the residue was flushed. When the ETT position was found satisfactory, the excessive length of ETT was cut. Staff were not aware that the catheter was not completely retrieved at the time of ETT cutting. 0n the next day, X-ray imaging revealed that a suspected fragment of catheter was retained. The 18 mm catheter was expelled with faeces uneventfully after 12 days. Key contributing factors in this incident were the following: 1. Lack of a standardized guideline on ETT shortening and surfactant administration. 2. Ineffective communication between doctors and nurses. Recommendations to prevent similar patient safety incidents are provided.7/7/2015 8:47:51 AMrétention involontaire de corps étrangers (RICE), réduction de la sonde endotrachéale, communication https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseGeneral Patient Safety;Patient Safety Incident
Bathing of Newborn Babies and Infection Prevention18828NSW05211/10/2011 7:00:00 AMPediatricAustraliaNew South Wales Department of Health (Australia)This safety notice discusses the dangers of bathing newborns immediately after birth while acknowledging the need to practice standard precautions in infection prevention and control within the health care environment. Skin flora of newborns is unique and the following must be considered: • Newborn babies require maintenance of normal skin flora to protect them from infection. Bathing a baby immediately after birth removes the normal skin flora and exposes baby to infection. • Newborn babies take some time to regulate their body temperature. Bathing a baby immediately after birth can lead to hypothermia. • Bathing a baby immediately after birth interferes with recommended skin-to-skin contact between baby and mother, and the establishment of infant feeding.5/11/2020 2:15:19 AMprécautions standard, flore cutanée, lutte contre les infections et contrôle des infections, ***IPC, matériel de protection personnel, **EPI, hygiène des mains, technique https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalsePatient Safety Incident
Bathing of Newborn Babies and Infection Prevention169751011/10/2011 7:00:00 AMPediatricAustraliaNew South Wales Department of Health (Australia)This alert discusses the patient safety incidents which can occur when bathing newborn babies. Standard precautions to prevent infection are in place to reduce the risk of transmission of micro-organisms from both recognised and unrecognised sources of infection in the healthcare setting. However, in the care of newborn babies, the following must be noted: • Newborn babies require maintenance of normal skin flora to protect them from infection. Bathing a baby immediately after birth removes the normal skin flora and exposes baby to infection. • Newborn babies take some time to regulate their body temperature. Bathing a baby immediately after birth can lead to hypothermia. • Bathing a baby immediately after birth interferes with recommended skin-to-skin contact between baby and mother, and the establishment of infant feeding. Therefore, it is recommended that routine bathing of the newborn immediately after birth is not recommended, except when there is a risk of vertical transmission of an infection from the mother, such as hepatitis B, hepatitis C or HIV, as per local protocols.5/11/2020 2:15:46 AMprécautions normales, prévention et contrôle des infections, hygiène des mains, équipement de protection individuelle, objets tranchants, technique aseptique, hygiène du milieu https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalsePatient Safety Incident
Bathing of Newborn Babies and Infection Prevention171681010/11/2011 6:00:00 AMPediatricAustraliaNew South Wales Department of Health (Australia)This alert discusses the patient safety incidents which can occur when bathing newborn babies. Standard precautions to prevent infection are in place to reduce the risk of transmission of micro-organisms from both recognised and unrecognised sources of infection in the healthcare setting. However, in the care of newborn babies, the following must be noted: • Newborn babies require maintenance of normal skin flora to protect them from infection. Bathing a baby immediately after birth removes the normal skin flora and exposes baby to infection. • Newborn babies take some time to regulate their body temperature. Bathing a baby immediately after birth can lead to hypothermia. • Bathing a baby immediately after birth interferes with recommended skin-to-skin contact between baby and mother, and the establishment of infant feeding. Therefore, it is recommended that routine bathing of the newborn immediately after birth is not recommended, except when there is a risk of vertical transmission of an infection from the mother, such as hepatitis B, hepatitis C or HIV, as per local protocols.5/11/2020 2:16:13 AMprécautions normales, prévention et contrôle des infections, hygiène des mains, équipement de protection individuelle, objets tranchants, technique aseptique, hygiène du milieu https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalsePatient Safety Incident
A newborn boy of immigrant parents had a circumcision performed1711614810/1/2010 6:00:00 AMCare ManagementUnited States of AmericaNew Jersey Department of Health and Senior Services (USA)This alert describes a surgical patient safety incident related to miscommunication due to a language barrier. A newborn boy of immigrant parents had a circumcision performed. The father later stated that he did not want his son circumcised. The nurse discussed the circumcision with the mother and father in the delivery room immediately after the child was born while helping the mother breast feed the baby. The mother did not speak English; the nurse did not feel there was a language barrier with the father. The mother signed the permission form and a covering obstetrician performed the circumcision. Two strategies to prevent this type of patient safety incident are provided.7/7/2015 8:47:48 AMbarrière linguistique, anglais comme langue seconde, consentement éclairé, consentement écrit, communication https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseGeneral Patient Safety;Patient Safety Incident
Keeping Newborn Babies with a Family History of MCADD Safe in the First Hours and Days of Life170579310/26/2011 6:00:00 AMObstetrics & GynecologyUnited KingdomNational Health Service Commissioning Board (England and Wales)This alert addresses the patient safety incidents of medium-chain acyl-CoA dehydrogenase deficiency (MCADD), a rare inherited disorder where the body cannot metabolise fat properly. With a regular intake of food, individuals can live a normal healthy life, but prolonged fasting or illnesses with vomiting can lead to encephalopathy, coma or sudden death. The disease affects about one in 10,000 babies born in the UK but if both parents are MCADD carriers, there is a one-in-four chance of their child being born with MCADD. In the first 2-3 days of life, when regular feeding is not fully established, new born babies are heavily dependent on fat metabolism for their energy needs and those with MCADD are especially vulnerable to early neonatal death. Screening for MCADD is part of the UK new born screening programme, which is offered to all babies in England at 5-8 days of age. A baby with a family history of MCADD should have special rapid testing 24 to 48 hours after birth on a blood spot card marked ‘Family history of MCADD’ but must also be given a special feeding regimen from the moment of birth (see resources from the British Inherited Metabolic Diseases Group. Between 1 January 2006 and 30 June 2011, the National Reporting and Learning System received two reports of deaths of newborn babies from MCADD who were born to families with a history of the disease. It appeared that although the mothers had mentioned the family history to healthcare staff when they were pregnant, the staff were not aware of the significance of MCADD, and therefore did not arrange any specialist referrals, special feeding regimen or observation. Six additional ‘no harm’ incidents reported to the NRLS indicated similar omissions, fortunately without adverse effects. The alert provides several recommendations targeted at General Practitioners, NHS organisations providing obstetric, midwifery, neonatal or paediatric services, and specialist centres for inherited metabolic disease.5/11/2020 2:15:59 AMdéficit de l'acyl-CoA déshydrogénase des acides gras à chaîne moyenne (déficit en MCAD), héréditaire, congénital, décès néonatal, métabolisme des graisses, dépistage, antécédents https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseProcedure Associated Conditions;Patient Safety Incident
Data Snapshot: Pediatric Laboratory Events17351322010/1/2013 6:00:00 AMLaboratoryUnited States of AmericaPennsylvania Patient Safety Authority (USA)This alert reviews the patient safety incidents of pediatrics undergoing laboratory procedures. Specimen collection problems are costly in terms of the time required to secure a new specimen, trauma inflicted on the patient, potential delay in diagnosis and treatment, and financial costs of additional resources used. The pediatric population has a heightened vulnerability to and fear of specimen collection, especially with venipunctures. An analysis of laboratory-related events that occurred in the pediatric population was conducted; all types of specimen collection (e.g., blood, urine, biopsies) were included. For the purposes of this study, "pediatrics" encompasses newborns through age 21, based on a 1988 American Academy of Pediatrics official statement. Between January 2010 and December 2012, the laboratory-related events that occurred accounted for 57.6% (n = 11,477 of 19,923) of the pediatric-related, procedural-errorrelated events reported and 14.0% (n = 11,477 of 81,701) of the total pediatric events reported by Pennsylvania children’s hospitals, acute care hospitals, community hospitals, rehabilitation hospitals, ambulatory surgical facilities, and birthing centers that provided care for pediatric populations. The laboratory events compiled were as follows: - Specimen quality problems (e.g., wrong color tubes used, blood hemolyzed) -- 21.9% - Specimen label incomplete or missing - 20.5% - Specimen mislabeled - 16.5% - Results missing or delayed - 9.5% - Other (e.g., tourniquet left on, missing patient identification bands, lab equipment failed) - 7.9% - Tests ordered but not performed - 7.5% - Wrong patient (e.g., ordered on wrong patient,performed test on wrong patient) - 4.4% - Specimen delivery problem - 3.6% - Wrong result - 3% - Tests not ordered - 2.6% - Wrong test ordered - 1.7% - Wrong test performed - 1% Ensuring proper patient identification; proper collection, handling, and labeling of specimens; and safe delivery of the specimens to the laboratory can reduce patient stress, financial costs, the use of additional resources, and the occurrence of delayed results, delayed patient care, additional needlesticks, and additional treatments (e.g., transfusions).5/11/2020 2:16:48 AMmauvais étiquetage du prélèvement, identification du patient, mauvais patient, mauvaise épreuve, mauvais résultat, sang, urine, biopsie, veinopuncture, mélange d'identifiants de https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalseProcedure Associated Conditions;Patient Safety Incident