Event Reporting Category

Categories

Equipment

Identifying a Supply Issue Affecting Patient Safety

Equipment

Nursing

Nutrition

A facility called the Patient Safety Authority with a concern regarding misplacements of nasogastric feeding tubes.

Reporting a Networkwide Supply Shortage

Equipment

Monitoring

Telemetry leads were on backorder, and replacement leads were being used instead.

Reporting a Problem Catches Unrecognized Systemwide Failure

Equipment

Monitoring

At around 10 p.m. on a Sunday, a registered nurse reported to her unit director that her telemetry pager was not receiving alarms for a patient with arrhythmias, although it had been working when she came on the night shift at 7 p.m

Building a Safety Culture and Encouraging Reporting

Electronic Health Record

Equipment

Laboratory leadership embracing a culture of transparency and safety at their hospital—encouraging reporting through positive recognition of staff and continuous process improvement to mitigate operational risks—has increased reporting and resulted in positive changes to keep patients safe.

Catching Weight Errors in Real-Time

Electronic Health Record

Equipment

Following a significant harm event related to how patient weights were obtained at a hospital, the organization invested in replacing all hospital and clinic scales with metric-only scales; however, events continued to occur.

Changing Procedures for Changing Trachs

Equipment

Respiratory

Three safety events involving bedside tracheostomy (trach) changes—downsizing and occasionally upsizing—occurred at a hospital in one year, one of which was self-reported by a respiratory therapist to the respiratory manager.

Facility Invests in Catching Weight Errors

Equipment

After a staff member at a large hospital identified weight errors in which patient weights were entered as pounds instead of kilograms and escalated the issue before the patients experienced significant harm, the hospital invested more than $500,000 to improve the patient weighing process and reduce the occurrence of weight errors to zero.