Patient Safety Action Alerts
Informed by reports submitted to Oregon’s Patient Safety Reporting Program, Action Alerts provide up-to-date information about specific experiences and threats to patient safety in ambulatory surgery centers, hospitals, pharmacies, and nursing homes. Each alert provides recommendations for how healthcare providers can take action to identify and prevent similar events from occurring in Oregon facilities. If your facility has observations or lessons learned that could improve patient safety, please contact one of our patient safety consultants.
To read additional, national cases that highlight patient safety issues and concerns, see:
Morbidity and Mortality Rounds on the Web, Agency for Healthcare Research and Quality
Healthcare Risk Control Public Alerts, ECRI Institute
Colored Wristband Use
Standards for Use Throughout Your Facility
Posted: 5-31-2013
Wheels Off for Safety
Wheeled Equipment Leads to Variety of Unnecessary Falls
Posted: 5-3-2013
A Place for Everything
Preventing inadvertent use of unsterilized instruments
Posted: 3-28-2013
A Grating Problem
A Patient Safety Concern Just Outside the Clinical Setting
Posted: 3-4-13
When Two Rights Result in a Wrong
Missing information leads to epidural hematoma
Posted: 1-28-2013
Potentially Contaminated Medication
Epidural Steroid Injections Associated with Meningitis and Stroke
Posted: 10-5-2012
Potential Hazards of Clock Synchronization Errors
How clock disagreement within and across systems can increase adverse event risk
Posted: 10-2-2012
Using Checklists to Prevent Harm in Suicidal Patients
Two cases identify situations where checklist may prevent harm to suicidal patients
Posted: 6-28-2012
Medication Double Message?
Conflicting medication instructions cause patient confusion before surgery
Posted: 5-10-2012
Burst Birthing/Exercise Ball Near Miss
Laboring patient experiences collapse of birthing ball
Posted: 5-10-2012
Enema Tubing Illusion
Equipment design contributes to misunderstanding of how to use
Posted: 5-10-2012
