Categories
Thumbnail associated with Event Reporting story titled: Taking Stock of Fluids to Find the Right Solution
Taking Stock of Fluids to Find the Right Solution
Equipment
Medication
Nursing
After a hospital received several event reports of wrong and expired intravenous (IV) fluids caught before reaching patients, the medication safety officer investigated how these products were supplied. This institution purchases all their plain IV fluids from one manufacturer, so the products appear very similar.
Thumbnail associated with Event Reporting story titled: Identifying a Supply Issue Affecting Patient Safety
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.
Thumbnail associated with Event Reporting story titled: Reducing the Risk of Lab Errors
Reducing the Risk of Lab Errors
Lab
Nursing
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.
Thumbnail associated with Event Reporting story titled: Reporting System Issue Reveals a Bigger Problem
Reporting System Issue Reveals a Bigger Problem
Nursing
Sepsis
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.
Thumbnail associated with Event Reporting story titled: Improving Employee Safety
Improving Employee Safety
Emergency Department
Nursing
Opioids
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.
Thumbnail associated with Event Reporting story titled: Assessing Respiratory Risk With Opioid Use
Assessing Respiratory Risk With Opioid Use
Monitoring
Nursing
Opioids
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.
Thumbnail associated with Event Reporting story titled: Diabetes Task Force Improves Care
Diabetes Task Force Improves Care
Electronic Health Record
Emergency Department
Nursing
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.