Search Results for: alert
Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants
July 30, 2019
The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commission collects information on serious events, and then aggregates the learning from those into Sentinel Event Alerts. They are designed to notify the healthcare community […]
CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms
July 8, 2019
Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease statusExamples include:Patient with suspect TB transferred to floor without making staff aware.Patient transferred to ICU from the ED without sharing information that patient was positive for MRSA.Patient directly admitted without informing receiving personnel that […]
CPS Safety Alert/Watch – Culture can Improve the Control of Multi-Drug Resistant Organisms
July 8, 2019
ISSUE:A number of events reported to CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status.Examples include:~Patient with suspected TB transferred to floor without making staff aware.~Patient transferred to ICU from ED without sharing information that patient was positive for MRSA.~Patient directly admitted without informing receiving personnel that swab testing […]
CPS Safety Alert/Watch – LIFEPAK 15 Monitor/Defibrillators
February 15, 2019
BACKGROUND: Stryker Launches Voluntary Field Action for Specific Units of the LIFEPAK 15 Monitor/Defibrillator. Stryker has become aware that certain LIFEPAK 15 Monitor/Defibrillators were reported to experience a lock-up condition after a defibrillation shock was delivered. This condition is defined as a blank monitor display with LED lights on, indicating power to the device, but […]
CPS Safety Alert/Watch – Look Alike Sound Alike Medications
August 10, 2018
Medication: Kenalog 40 mg/1 ml single dose vial (contents 1 ml) Kenalog 200 mg/5 ml multi-dose vial (contents 5 ml; concentration 40 mg/1 ml) Actionable Items to Mitigate Risk: Remain consistent with ordering practices. If it is your organization’s practice to routinely order single dose vials, continue ordering single dose vials. Do not switch from […]
CPS Safety Watch/Alert – Violence Against Healthcare Workers
June 5, 2018
SAFETY ALERT: Violence Against Health Care Workers Includes: Verbal Threats Hitting Biting Scratching Kicking Stalking Harassment ACTIONABLE ITEMS TO MITIGATE RISK Review policies and education of staff pertaining to the recognition and de-escalation of hostile and aggressive behavior by patients. Evaluate the need for security personnel and mental health professionals to assist with identification and […]
Joint Commission Sentinel Event Alert #59
April 17, 2018
The Joint Commission’s timely Sentinel Event Alert #59 relative to physical and verbal violence against health care workers reminds me of the #Me Too movement. For too long providers have tolerated and ignored the inappropriate and sometimes harmful actions by patients, visitors and sometimes co-workers. Everyone knows it’s often challenging to provide high quality, safe […]
CPS Safety Watch/Alert – Respiratory Compromise
March 15, 2018
BACKGROUND Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation. Respiratory Compromise creates problems that are often serious and potentially life-threatening, but they are almost always preventable with the […]
CPS Safety Watch/Alert – Medication Shortages
September 14, 2017
Medication Shortages: Adversely affect drug therapy Can cause complications in medical procedures Contribute to medication errors Create frustration for providers & patients ACTIONABLE ITEMS TO MITIGATE RISK Validate details of shortage & check with suppliers Determine stock on hand Determine purchase history & true use Estimate time until shortage impacts agency & length of shortage […]
CPS Safety Watch/Alert: Elopement
July 7, 2017
TARGET AUDIENCE Nursing, Medical & other Clinical Leaders Clinical Educators Patient Safety/Quality Improvement Leaders Legal/Risk Management And Leaders in: Hospitals EMS LTC Home Care SAFETY WATCH: ELOPEMENT Safety Watch v4-2 Elopement Emergency Services are increasingly dealing with patients who elope prior to receiving care, many times due to lengthy wait times. Patient safety issues associated […]