Resources

According to the report Never Events for Hospital Care in Canada, three of the fifteen never events are associated with patient trauma during hospitalization:Patient death or serious harm due to uncontrolled movement of a ferromagnetic object in an MRI area,Patient death or serious harm due to an accidental burn andPatient death or serious harm as a result of transport of a frail patient, or patient with dementia, where protocols were not followed to ensure the patient was left in a safe environment (Canadian Patient Safety Institute 2015)

Surgery and other invasive procedures carry risk of complication and mortality (Magee et al., 2018). Unintentional or accidental cuts, punctures or perforations can occur in both surgical and medical procedures.

The Hospital Harm Improvement Resource links measurement and improvement by providing evidence-informed practices that will support patient safety improvement efforts.

It's time to have a conversation about safety in the home.

Many adult hospital inpatients require intravenous (IV) fluid therapy to prevent or correct problems with their fluid and/or electrolyte status. This may be because they cannot meet their normal needs through oral or enteral routes (related for example to swallowing problems or gastrointestinal dysfunction) or because they have unusual fluid and/or electrolyte deficits or demands caused by illness or injury (e.g., high gastrointestinal or renal losses). Deciding on the optimal amount and composition of IV fluids and the best rate at which to administer them can be a difficult task. Decisions must be based on careful assessment of the patient's individual needs (National Institute for Health and Care Excellence (NICE) 2013).

Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes with shunting of blood to bypass capillary exchange beds (Procter, 2020). It is a clinical state that occurs when a mismatch arises between oxygen supply and metabolic demand, resulting in cellular hypoxia. If not recognized and treated appropriately, shock will ultimately progress to organ failure (Broussard & Ural, 2018; Gaieski & Mikkelsen, 2018; Vincent & De Backer, 2013). It is one of the leading causes of death in hospitalized patients (Nichol & Ahmed, 2014).

Anemia is a decrease in the number of red blood cells (RBCs), hematocrit (Hct), or hemoglobin (Hb) content. Anemia is not a diagnosis; it is a manifestation of an underlying disorder. Anemia can occur as the result of one or more of three basic mechanisms; blood loss, deficient erythropoiesis, and excessive hemolysis (Lichtin, 2017). The focus of this resource is on anemia related to acute blood loss (acute posthemorrhagic anemia) and hemorrhagic disorders due to circulating anticoagulants.

Nosocomial pneumonia can be classified into various subtypes, the most common of which is aspiration pneumonia (Marik, 2011). Aspiration is defined as the misdirection of oropharyngeal or gastric contents into the larynx and lower respiratory tract. Aspiration pneumonia then results when orogastric secretions colonized with bacteria produce an infectious response in the lungs. Aspiration of sterile contents causes chemical inflammation or aspiration pneumonitis (Marik, 2011).

Hemorrhage or hemorrhagic anemia refers to anemia secondary to acute blood loss associated with a medical or surgical procedure. Bleeding is a potential complication of any surgical procedure, and the risk is proportional to the size and complexity of the surgery. High blood loss is associated with certain types of surgery such as cardiac and liver surgeries, certain orthopaedic procedures (such as hip replacement) and obstetric surgery. Mortality may be greatly increased when severe bleeding occurs during the operative procedure (National Institute for Health and Care Excellence (NICE), 2014).