In this section :
- Hospital harm is everyone’s concern
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Hospital Harm Improvement Resource
- How to Use the Hospital Harm Measure for Improvement
- Learning from Harm
- General Patient Safety Quality Improvement and Measurement Resources
- Hypoglycemia: Introduction
- Aspiration Pneumonia: Introduction
- Delirium: Introduction
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Infusion, Transfusion and Injection Complications: Introduction
- Infusion, Transfusion and Injection Complications: Discharge Abstract Database
- Infusion, Transfusion and Injection Complications: Importance to Patients and Families
- Infusion, Transfusion and Injection Complications: Clinical and System Reviews, Incident Analyses
- Infusion, Transfusion and Injection Complications: Measures
- Infusion, Transfusion and Injection Complications: Success Stories
- Infusion, Transfusion and Injection Complications: References
- Medication Incidents: Introduction
- Obstetric Hemorrhage: Introduction
- Patient Trauma: Introduction
- Pneumonia: Introduction
- Pneumothorax: Introduction
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Post Procedural Infections: Introduction
- Post Procedural Infections: Discharge Abstract Database
- Post Procedural Infections: Importance to Patients and Families
- Post Procedural Infections: Clinical and Systems Reviews, Incident Analyses
- Post Procedural Infections: Measures
- Post Procedural Infections: Success Stories
- Post Procedural Infections: References
- Pressure Ulcer: Introduction
- Sepsis: Introduction
- UTI: Introduction
- Venous Thromboembolism: Introduction
- Wound Disruption: Introduction
- Obstetric Trauma: Introduction
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Procedure-Associated Shock: Introduction
- Procedure-Associated Shock: Discharge Abstract Database
- Procedure-Associated Shock: Importance to Patients and Families
- Procedure-Associated Shock: Clinical and System Review, Incident Analysis
- Procedure-Associated Shock: Measures
- Procedure-Associated Shock: Success Stories
- Procedure-Associated Shock: References
- Selected Serious Events: Introduction
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Electrolyte and Fluid Imbalance: Introduction
- Electrolyte and Fluid Imbalance: Discharge Abstract Database
- Electrolyte and Fluid Imbalance: Importance to Patients and Families
- Electrolyte and Fluid Imbalance: Clinical and System Reviews, Incident Analyses
- Electrolyte and Fluid Imbalance: Measures
- Electrolyte and Fluid Imbalance: Success Stories
- Electrolyte and Fluid Imbalance: References
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Anemia – Hemorrhage (Health Care / Medication Associated Condition): Introduction
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Discharge Abstract Database
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Importance to Patients and Families
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Clinical and System Reviews, Incident Analyses
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Measures
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Success Stories
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): References
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Anemia – Hemorrhage (Procedure-Associated Conditions): Introduction
- Anemia – Hemorrhage (Procedure-Associated Conditions): Discharge Abstract Database
- Anemia – Hemorrhage (Procedure-Associated Conditions): Importance to Patients and Families
- Anemia – Hemorrhage (Procedure-Associated Conditions): Clinical and System Reviews, Incident Analyses
- Anemia – Hemorrhage (Procedure-Associated Conditions): Measures
- Anemia – Hemorrhage (Procedure-Associated Conditions): Success Stories
- Anemia – Hemorrhage (Procedure-Associated Conditions): References
- Birth Trauma: Introduction
- Device Failure: Introduction
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Infections due to Clostridium difficile, MRSA or VRE: Introduction
- Infections due to Clostridium difficile, MRSA or VRE: Discharge Abstract Database
- Infections due to Clostridium difficile, MRSA or VRE: Importance to Patients and Families
- Infections due to Clostridium difficile, MRSA or VRE: Surveillance, Outbreak Management
- Infections due to Clostridium difficile, MRSA or VRE: Clinical and System Reviews, Incident Analyses
- Infections due to Clostridium difficile, MRSA or VRE: Measures
- Infections due to Clostridium difficile, MRSA or VRE: Success Stories
- Infections due to Clostridium difficile, MRSA or VRE: References
- Laceration: Introduction
- Retained Foreign Body: Introduction
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Viral Gastroenteritis: Introduction
- Viral Gastroenteritis: Discharge Abstract Database
- Viral Gastroenteritis: Importance to Patients and Families
- Viral Gastroenteritis: Surveillance, Outbreak Management
- Viral Gastroenteritis: Clinical and System Reviews, Incident Analyses
- Viral Gastroenteritis: Measures
- Viral Gastroenteritis: Success Stories
- Viral Gastroenteritis: References
Device Failure: Success Stories
One important success factor that will enhance the safety of medical devices is to gain trust from the frontline healthcare providers and ensure that their incident reports will be reviewed to resolve the errors and prevent future similar errors. These individuals, therefore, should be kept abreast of any relevant developments and receive timely feedback (Polisena, 2014).
HSO – Leading Practices
Reporting of Adverse Events in Reprocessing of Medical Devices
Hôpital Charles LeMoyne, Quebec. 2011
This a system for identifying risks in reprocessing medical devices and analysing the underlying causes. It is used to develop a profile of the risks inherent in the process for reprocessing reusable medical devices. Using this practice, information on reprocessing is also disseminated throughout the organization, primarily to the risk manager and management. Each adverse event is identified either by the clinicians who notice errors in their trays during use or by computer searches in the organization's tracking software. These events are recorded in a database, Access, and the underlying causes are analysed to develop and implement measures to prevent recurrence (HSO, 2011).
The Development of an Interdisciplinary Smart Pump Working Group reporting to Safe Medication Practices for the Management of Parenteral Administration using Smart Pump Technology
Royal Victoria Regional Health Centre, 2019
https://healthstandards.org/leading-practice/development-interdisciplinary-smart-pump-working-group-reporting-safe-medication-practices-management-parenteral-administration-using-smart-pump-technology/
The Smart Pump Working Group is an inter-professional group (clinical educators, front-line pharmacists, Professional Practice Manager, Pharmacy Manager, Biomedical Engineering representative, Network Administrator from Information Technology Services) that reports to Safe Medication Practices Committee. Its primary mandates are to review current practices of smart pump devices within the organization and to develop recommendations to the Safe Medication Practices Committee by utilizing the data from smart pumps to improve safety and develop an on-going process for smart pump updates and continued data analysis. It is also mandated to review, on an on-going basis, any required additions/changes to ensure consistent, scheduled drug library (DL) updates occur, aligning with medication safety standards and recommendations from organizations such as ISMP Canada.
The Working Group meets monthly, and the work accomplished has led to a drug library compliance rate of greater than 98 per cent for over one year and the almost elimination of medication errors related to I.V. administration of medications due to over-riding parameters.
We feel that this is innovative and transformative because, in a meeting with ICUMedical, when we were reviewing next steps in report development for presentation to our hospital executives, ICUMedical (the manufacturers for the Plum 360 Smart Pumps) had indicated that there were not aware of any other institution in Canada that had an efficient and effective Working Group, and who are using the actual data for on-going quality improvements. They were the ones who had indicated that we should be putting this initiative forward as a Leading Practice (HSO, 2019).
Device Failure
