Resources

Patients expect safe care, and healthcare providers strive to deliver care that results in better health and safe, effective outcomes for patients. However, events that harm patients do occur while care is being provided, or as a result of that care. While risk is an inherent part of care, we know that many of these events that cause harm can be prevented using current knowledge and practices. Many of these events occur only rarely, but all can have a severe impact on the lives and well-being of patients.

Venous Thromboembolism (VTE) is the third most common cause of vascular mortality worldwide and comprises deep-vein thrombosis (DVT) and pulmonary embolism (PE) (Nicholson, et al., 2020). DVT occurs when an abnormal blood clot forms inside a vein deep in the leg. DVT may cause leg pain and/or swelling but is often clinically silent. PE occurs when all or part of a DVT breaks away from its site in a vein and travels through the venous system to lodge in the lungs. PE may cause chest pain, shortness of breath, tachycardia, hemoptysis, or pre-syncope but is often clinically silent. In clinical practice, about two-thirds of VTE episodes manifest as DVT and one-third as PE with or without DVT (Nicholson, et al., 2020).

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.