|Data Snapshot: Maternal Serious Events||18377||3678||12/1/2016 7:00:00 AM||Obstetrics & Gynecology||United States of America||Pennsylvania Patient Safety Authority (USA)||This alert discusses patient safety incidents of 537 maternal events collected over a 5 year period of January 1, 2011 to December 31, 2015. The top five event categories in order of frequency were (1) unanticipated blood transfusion, (2) laceration of the birth canal, (3) unplanned transfer to the intensive care unit, (4) postpartum hemorrhage, and (5) bladder injuries. These categories were not necessarily independent (e.g., a patient may have required an unanticipated blood transfusion and an unplanned transfer to the intensive care unit). Of the 537 events analyzed, 11 (2.0%) resulted in death. Patient stories of each category are provided in the alert.||5/11/2020 2:18:42 AM||placenta, césarienne, hystérectomie, transfusion sanguine, lacération, filière pelvigénitale, transfert imprévu vers l'unité de soins intensifs, hémorragie postpartum, vessie ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Serious Untoward Events Involving Medication||17854||3068||4/1/2013 6:00:00 AM||Medication||Hong Kong||Hong Kong Hospital Authority||This alert describes 25 patient safety incidents involving medication. Of the 22 medication errors, there were:
- 9 “Known Drug Allergy”, including penicillin, paracetamol,
chlorpheniramine and Promethazine Compound Linctus;
-5 “use of Dangerous Drugs”, involving incorrect infusion rate
of morphine and giving wrong dose of lorazepam;
- 2 use of anticoagulants involving incorrect route of injection of heparin and giving wrong concentration of heparin
- 2 use of inotropic agent, related to giving incorrect dose of
dopamine and dobutamine; and
- 4 use of "other medication" related giving incorrect dose of drug
Of the 3 patient misidentification incidents, there were:
- 2 misidentification of patient during drug administration; and
- 1 misidentification of patient on the electronic patient record summary
Several recommendations to prevent medication incidents relating to giving a drug to which there is a known drug allergy are provided.||7/7/2015 9:17:46 AM||antithrombotic agents (anticoagulants),
inotropic medications, IV,
narcotics/opiates, IV, transdermal, and oral allergie connue aux médicaments, antécédents d'allergies, mauvais ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Medication Safety;Medication Incident;Patient Safety Incident|
|Care Delays Can Lead to Serious Adverse Events||18335||3712||10/3/2016 6:00:00 AM||Care Management||United States of America||Oregon Patient Safety Commission (USA)||This alert discusses the patient safety implications when care is delayed. Care delays, including delay in treatment or intervention and failure to rescue, have the potential to cause serious harm or death—especially when there is a delay in providing an intervention necessary to sustain life. The alert provides a list of factors which have contributed to adverse events related to delayed care. Recommended actions are provided to address three factors of clinical emergency preparedness that warrant attention in nearly every point of care:
1. Rapid access to functioning equipment and non-expired, required supplies and medications
2. Knowledgeable and trained staff to manage the clinical emergency at all times of the day and night
3. Ability to monitor the systems to ensure that clinical staff maintain a state of readiness during all hours of operation.
||2/11/2019 10:53:40 PM||laryngoscopes, suction vacuums, pressure bags, code carts, medication carts laryngoscopes, aspirateurs, sacs à pression, chariots pour code d’alerte, chariots à médicaments ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Varenicline (CHAMPIX)-Serious Psychiatric Side Effects||18622||NSW28||5/1/2009 6:00:00 AM||Medication||Australia||New South Wales Department of Health (Australia)||This Safety Information discusses patient safety incidents of possible suicidal and aggressive behaviour resulting from use of a smoking cessation drug. ||7/7/2015 9:22:35 AM||"Patient death or serious disability associated with a medication error (e.g., errors "pharmacie communautaire, santé mentale, urgence, patients externes Care Management Events ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Medication Safety;Medication Incident;Patient Safety Incident|
|Infusion Pumps: Preventing Future Adverse Events||17686||JC23||11/1/2000 7:00:00 AM||Medical Device||United States of America||The Joint Commission (USA)||"Mishaps involving the use of infusion pumps have led to deaths and near-fatal drug overdoses. The main problem is with the use of pumps that do not provide protection from the free-flow of intravenous fluid/medication into the patient. Causes of these incidents include: human error, staffing patterns, work pressures, having many different concentrations of critical care drugs, and lack of standards. Many errors could be prevented if organizations only use infusion pumps that require set-based free-flow protection. This alert describes actions to reduce risk."||5/11/2020 2:12:09 AM||Patient death or serious disability associated with the use or function of a device in Product or Device Events Décès ou grave invalidité d'un patient par suite de l'utilisation ||4||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Patient Safety Incident|
|Allopurinol and Azathioprine: A Serious and Known Drug Interaction.||18698||NSW35||5/1/2009 6:00:00 AM||Medication||Australia||New South Wales Department of Health (Australia)||This Safety Notice discusses patient safety incidents where patients experienced harm due to receiving two drugs that posed a serious drug interaction.
One case is described where the patient was on existing azathioprine treatment when admitted to hospital and allopurinol was added by a consulting medical team. Opportunities to identify the interaction were missed by the consulting and treating medical teams and pharmacists. Contributing factors to the incident included the following:
- The consulting medical team did not assess the patient’s existing therapy when recommending treatment with allopurinol.
- The patient’s medicines were not thoroughly reviewed during their admission.
- The medical teams were unaware of the interaction and associated risks.
- The supervising pharmacist was not notified of the drug interaction alert automatically generated by the pharmacy dispensing software. ||7/7/2015 9:22:36 AM||"Patient death or serious disability associated with a medication error (e.g., errors Care Management Events "allopurinol (médicament contre la goutte), azathioprine ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Medication Safety;Medication Incident;Patient Safety Incident|
|SUBCUTANEOUS INSULIN can be FATAL or cause SERIOUS HARM if administered inappropriately||19428||VIC068||12/1/2008 7:00:00 AM||Medication||Australia||Victoria Department of Health (Australia)||"This Quality Use of Medicines Alert discusses patient safety incidents related to prescribing and administration of subcutaneous insulin. A wrong dose and/or wrong formulation of insulin has resulted. Several patient safety incidents are described. Contributing factors include the following:
- Using the non-approved abbreviation ‘U’ for units. Doses prescribed using the abbreviation ‘U’ for units has led to staff misinterpreting the ‘U’ as a ‘zero’ and resulted in a ten-fold increase in the dose administered.
- Insulin product names can be confusing and be misinterpreted. For example, names that include numbers, such as ‘NovoMix 30’ can be misinterpreted and the ‘30’ mistaken for the dose leading to an incorrect dose being administered.
- Insulin formulations, or their labels and packaging, may look alike and sound alike, for example Humalog and Humalog Mix 25.
- Large and variable dose ranges may mean that errors are less easily detected. For example, a large dose which is safe in one patient may be harmful in another.
- Ambiguous prescriptions or unusually large doses may not be queried prior to administration.
Numerous recommendations to prevent incidents are provided."||7/7/2015 9:23:45 AM||"Patient death or serious disability associated with a medication error (e.g., errors Care Management Events "insuline,
Humalog Mix ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Medication Safety;Medication Incident;Patient Safety Incident|
|Medical Device Tubing Misconnections May Result in Serious Harm||18334||3713||10/27/2016 6:00:00 AM||Medical Device||United States of America||Oregon Patient Safety Commission (USA)||This alert discusses the adverse events that can occur when tubing of medical devices is misconnected. Serious harm or death can result when a medication, substance (such as an enteral feeding) or gas is delivered via the wrong route. The alert identifies major factors contributing to tubing misconnection injuries. International Organization for Standardization (ISO) standards are currently being reworked to prevent misconnections by designing connectors that physically prevent connections with devices used for other medical applications. During the transition to the new ISO standards for tubing connections, healthcare organizations should implement practices to manage the risk of tubing misconnections. The alert provides the Joint Commission risk management tips for clinicians.||5/11/2020 2:18:31 AM||alimentation entérale, gaz, mauvaise voie, erreurs de connexion, stress, fatigue, distractions, éclairage, facteurs environnementaux, syndrome du spaghetti, retracer, déplacement ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Confusing AmBisome® and Fungizone® against fungal infections can have serious consequences||18894||4092||1/5/2020 7:00:00 AM||Medication||Denmark||This alert draws attention to the difference between AmBiosome® and Fungizone® in treating fungal infections; a mix-up between these products could result in serious adverse events and even death. Both contain amphotericin B but AmBiosome® is a liposomal-based formulation while Fungizone® is a non-lipid based formulation. Fungizone® and AmBisome® are not substitutable and can therefore not replace each other; they must be given in different dosages and at different infusion rates. The alert provides dosing and infusion rate guidelines for each drug and a recommendation to support safe use of these products.||2/14/2022 7:48:01 PM||soins de courte durée, oncologie, médecine, médicament, soins infirmiers, pharmacie amphotéricine B (FungizoneMD),
amphotéricine B liposomale (AmBisomeMD ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Sentinel Events – Patient Suicide||19257||PC85||7/1/2009 6:00:00 AM||Mental Health||Hong Kong||Hong Kong Hospital Authority||"This alert concerns multiple incidents where six patients committed suicide while in hospital, four patients committed suicide during home leave, and one patient was found missing from the hospital and committed suicide outside the hospital. Half of these patients had mental illness, the others had cancer, chronic illness, or permanent disabilities. Key contributing factors include an unstable mental status and depression, inadequate awareness of environmental risks or dangerous objects that may facilitate suicidal acts, and ineffective communication amongst healthcare professionals, patients and their care-givers. A Suicidal Risk Screening Tool would be indicated if a patient that was admitted because of suicidal attempts or idea, patient expresses suicidal idea or self-harm behaviour, or disclosure by relatives/friends that patient has suicidal inclination."||5/11/2020 2:13:25 AM||suicide, or attempted suicide, resulting in serious disability while being cared for in a Patient Protection Events "Suicide ou tentative de suicide d'un patient lui occasionnant une ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Patient Safety Incident|