Patient Safety

Patient safety is about managing and reducing risk to ensure that the care patients receive is as safe as possible. UHN has recently showcased lessons learned from recent incidents to communicate how a variety of risks can be avoided.

Canadian Patient Safety Week 2009 – Ask, Listen, Talk
Two patients with very similar names, order placed for a procedure on incorrect patient.

Case Study – Right Intervention, Wrong Location Patient received porto-cath in her chest rather than her stomach.

Learnings from Incidents – Patient Information Lost
Nurse printed out list containing Personal Health Information which was subsequently lost and disposed of.

Learnings from Incidents – Incorrect Medication Dispensed
Patient’s prescription changed, change was noted on the bottle but the patient continued to take the previous medication dose.

Learnings from Incidents – Losing Unencrypted Electronic Devices
Researcher backed up documents onto a USB. USB key has encryption but the feature was not activated.

Learnings from Incidents – Compressed Air/ Oxygen Mix Up
Patient was connected to Compressed Air rather than Oxygen for a period of 36 hours.

Patient transferred with another patients medications
When transferred from one unit to another, the patient was transferred with another patient’s medications.

Learnings from Incidents – Breaching privacy and security when using email
When setting up rules for her email inbox, a staff member inadvertently set up a rule that forwarded some of her internal messages to her external email account.

Medications incorrectly packaged
Two tablets of medication were found in one package rather than one tablet of medication

Impact of incorrect patient weight entered into EPR
Patient’s weight was incorrectly entered into the patent chart.

 

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