The Child Health Patient Safety Organization (PSO) releases Patient Safety Action Alerts to provide immediate notification of patient safety concerns. These alerts are approved for general distribution to improve pediatric safety and reduce patient harm. They are released publically to stimulate learning and ongoing collaboration to address serious, preventable and multi-center pediatric patient safety concerns.
This is a patient safety alert about how to mitigate injuries from thermal devices (hot or cold) that can cause thermal injuries (e.g., severe burns, ...
A neonate’s fingertip was amputated with scissors while removing tape around malfunctioning peripheral arterial line.
Wrong Size Tracheostomy Selection
A patient required increased oxygen, ventilator support, sedation and paralytics when the wrong-size cuffed tracheostomy tube was inserted.
Blind Pediatric NG Tube Placements
NG tube placement can lead to complications such as esophageal perforation, bronchopulmonary intubation, pneumothorax, hydrothorax, empyema, and ...