Safety Learning Summaries | Patient Safety

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Patient Safety

Safety Learning Summaries

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Below, you'll find a master listing of all Safety Learning Summaries. To search by web code, please hit CTRL+F on your keyboard and type in the code you are looking for.

1201-04	Challenges in caring for mental health patients with underlying medical conditions

1201-03	Surgery on Incorrect Limb

1201-02	Narcotic Administration in the ED

1201-01	A Fall in Acute Care

1110-04	Intrauterine fetal death following placental abruption

1110-03	Suicide While On Pass

1110-02	Prosthesis Allergy

1110-01	Postoperative Pulmonary Embolus

1002-06	Elderly resident with a pressure ulcer receives care in several facilities.

1002-05	Cardiac patient collapses while undergoing a stress test.

1002-04	Personal care home resident experiences obstructed airway while eating toast.

1002-03	Wrong site x-rayed following misinterpretation of requisition.

1002-02	Confusion over surgical specimen pick-up.

1002-01	Patient with bacterial meningitis leaves an Emergency Department without being seen.

0908-008	Delay in treatment for severe congestive heart failure.

0908-007	Elevated serum magnesium in a premature infant receiving Total Parenteral Nutrition.

0908-006	Two patients with dementia circumvent alarm systems.

0908-005	Delay in diagnosis of ischemic bowel.

0908-004	Delay in diagnosis of a sports-related injury complication.

0908-003	Personal Care Home resident sustained a spinal fracture.

0908-002	Delay in instituting appropriate antibiotic treatment.

0908-001	Delay in instituting surgical care for fractured hip.

0903-06	Personal care home resident with intermittent urinary retention admitted to hospital for severe bladder infection

0903-05	Personal care home resident sustained hip fracture

0903-04	Elderly patient on psychotropic medications relocated to a different room and sustained a hip fracture

0903-03	Elderly patient with new hip pain found to have surgical instrument left in abdomen from previous surgery

0903-02	Ambiguity in assessment and resuscitation roles

0903-01	Community-acquired MRSA undiagnosed

0807-013	Patient death due to sepsis arising from deep sacral ulcer that developed following treatment for hip fracture.

0807-012	Resident given multiple medications intended for another resident required hospitalization for treatment of apneic spells and decreased level of consciousness.

0807-011	Confusion about dose of trans-dermal Fentanyl led to admission of an elderly patient for treatment of delirium secondary to acute opioid withdrawal.

0807-010	Medication errors during treatment of severe respiratory distress in an infant.

0807-09	Incomplete medication reconciliation (MedRec) results in double dose of blood pressure medications with hypotension and death.

0807-08	Recurrent respiratory depression related to narcotic analgesia.

0807-07	Multiple consultants and incomplete information sharing led to delayed recognition of esophageal perforation after fine needle biopsy of mediastinal nodes.

0807-06	Communication challenges complicated the management of pre-term labour with eventual neonatal death after 11 weeks in the Neonatal Intensive Care Unit.

0807-05	Incomplete communication of bleeding encountered during knee arthroplasty contributes in part to the delayed recognition of ischemic limb.

0807-04	Unclear communication and protocols led to death from a sudden aortic rupture in an adult patient involved in multi-vehicle collision.

0807-03	Delayed diagnosis of an unusual vascular complication of varicella in a child.

0807-02	Delayed diagnosis of disseminated Tuberculosis in a homeless person.

0807-01	Inadvertent insertion of an IV line into a premature infant’s artery results in peripheral ischemic damage to distal arm and hand.

0805-010	A fall with fracture in an elderly patient assisted to the commode by untrained staff.

0805-09	Equipment placement and design contribute to wrist injury during a specialized diagnostic test.

0805-08	Emergency repairs to a motorized wheelchair while the client was in the chair led to a fracture requiring a below the knee cast

0805-07	Completed suicide in patient with multiple medical problems and significant pain control issues, after discharge from acute care facility.

0805-06	Completed suicide prior to integration into community mental health services after discharge from acute care facility.

0805-05	Completed suicide during an overnight, unaccompanied, pass two weeks after admission to Psychiatry.

0805-04	Abbreviated medication order transcription led to administration of 200 mgm of Hydrochlorothiazide instead of Hydroxychloroquine and the need for Intensive Care Unit admission.

0805-03	A bolus of ten times the prescribed dose of Fentanyl via a patient-controlled analgesia (PCA) pump leads to respiratory arrest.

0805-02	Ten times the prescribed quantity of a vaccination administered to an infant.

0805-01	Administration of high dose Gentamycin according to low dose protocol leads to oliguria and Intensive Care Unit support.

0803-012	Inconsistent documentation (three separate records) with regards to a resident’s mobility functioning and requirements led to a fall with head injury and subsequent death.

0803-011	Delayed diagnosis of leg fracture after unwitnessed fall in cognitively impaired resident resulting in death several days later.

0803-010	A delayed diagnosis of a shoulder dislocation following an unwitnessed fall by an elderly patient receiving narcotics.

0803-09	An adult with special needs had a seizure and suffered a head injury while waiting in an Emergency Department.

0803-08	Delayed diagnosis of facial cellulitis and abscess four days after insect bite.

0803-07	Delayed diagnosis of perforated viscus following hip replacement surgery.

0803-06	Development of skin ulcers that ultimately required limb amputation following Buck’s traction in a patient with peripheral vascular disease.

0803-05	Administration of atracurium in place of midazolam necessitates ventilatory support.

0803-04	A delay in diagnosis of malignancy as a result of ineffective information exchanges between an Emergency Department, a specialty clinic, and a family physician.

0803-03	Administration of atracurium in place of midazolam necessitatess ventilatory support.

0803-02	Transition between Emergency Medical Services, community hospital and tertiary centre Emergency Departments, following a 15-foot fall results in death from major injuries.

0803-01	Administration of atracurium in place of midazolam necessitates ventilatory support.