A facility called the Patient Safety Authority with a concern regarding misplacements of nasogastric feeding tubes.
Staff in a busy, 30-bed geriatric unit at a community hospital escalated errors to their unit’s practice Council for event review. The Council’s investigation revealed system issues, particularly regarding lab orders, which were shared with leadership; for example, specimens being sent to the lab without required employee identifiers and the wrong patient label.
Many facilities rely on the Modified Early Warning Score (MEWS), a simple physiological assessment that helps identify a patient’s risk for clinical deterioration and mortality.
Just as reporting adverse events helps improve patient safety, reporting workplace incidents that have harmed or had the potential to harm employees can inspire change to protect healthcare staff as well as patients and visitors.
Opioid use results in decreased respiratory rate, low oxygen saturation, and sedation, a condition known as opioid-induced respiratory depression (OIRD), which may result in serious harm—including death or brain damage.
At one facility, over a few months several incidents occurred involving patients in diabetic ketoacidosis (DKA), a life-threatening complication in which too much acid (ketones) builds up in the blood, in both the emergency department and acute care.