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.

June 2014 Diagnostic Tests/Referrals
July 2013 Pressure Ulcers
June 2013 Oxygen Tubing
1207-05 Inpatient Suicide
1207-04 Choking episode in a personal care home
1207-03 Interfacility Transport
1207-02 Monitoring Continuous Oxygen in Long Term Care
1207-01 Suicide in Personal Care Home
1204-03 Orthopedic Prosthesis
1204-02 IUD Insertion
1204-01 Parenteral Drug Overdose
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.

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Traditional Territories Acknowledgement
The Winnipeg Regional Health Authority acknowledges that it provides health services in facilities located in Treaty One and Treaty Five territories, the homelands of the Métis Nation and the original lands of the Inuit people. The WRHA respects and acknowledges harms and mistakes, and we dedicate ourselves to collaborate in partnership with First Nation, Métis and Inuit people in the spirit of reconciliation.
Click here to read more about the WRHA's efforts towards reconciliation

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