Patient Safety Action Alerts

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 publicly to stimulate learning and ongoing collaboration to address serious, preventable and multi-center pediatric patient safety concerns.


Improving Identification of Patients at Risk for Human Trafficking
September 1, 2021

Individuals experiencing labor and sex trafficking/exploitation have been identified in all 50 U.S. states and the District of Columbia, in urban, suburban, and rural areas.

Improving Communication in the Diagnostic Process
April 22, 2020

Child Health PSO has identified a safety concern related to communication failures in the diagnostic process. This alert was developed after conducting a common cause analysis of the Child Health PSO database.

Wrong-site Surgeries/Procedures are Still Occurring When Site is Difficult to Mark
April 17, 2019

Patients experience wrong-site surgeries/procedures when surgical/procedural sites are difficult, or impossible, to mark (e.g., perineum, mucosal surfaces such as with frenectomy procedures, internal organs, casted limbs, lateralized organs), or when patients/families refuse site marking.

Central Vascular Access Devices: From Orders to Insertion
April 30, 2018

Inserting an inappropriate central vascular access device (CVAD) can result in additional procedures for placing the correct CVAD, which can delay needed therapy, and risk infection, vascular damage and other harm.

High-risk Pediatric Populations: Improving Safety and Reliability in Diabetes Care Management
June 28, 2017

This is a patient safety alert about an immediate safety concern related to treatment of pediatric patients diagnosed with diabetes.

Disinfection of Clinicians’ Personal Medical Devices to Prevent the Spread of Organisms
April 27, 2017

This is a patient safety alert about the disinfection of clinicians' personal medical devices to prevent spread of organisms.

Thermal Injury
February 28, 2017

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, pressure ulcers, blisters, scarring and wounds) in pediatric patients.

Silicone-Foley Catheter Balloon Rupture
July 22, 2016

Foley balloon rupture can lead to a urinary tract infection and/or sepsis requiring antibiotic therapy.

Recognition of Retained Foreign Body - Button Battery
July 21, 2015

Button batteries remain conductive when ingested and can cause tissue erosion and significant damage if not removed in a timely manner.

Pediatric Medication Concentration Standards With Retail Pharmacy
June 26, 2015

Error in dosing concentration resulted in a patient being readmitted to the PICU for head imaging and observation.

Potential for an Event Related to Patients Receiving Liquid Medications Through An Enteral Route
April 30, 2015

Children receiving small dose, high alert medications with the transition to the new ENFit syringes could experience variability in dosing.

Sustained or Extended Release Medication Fill and Administration Errors
July 1, 2014

Alert on assessing dispensing and verification procedures for high-risk medications such as sustained/extended release narcotics.

Fingertip Amputation
July 1, 2014

A neonate’s fingertip was amputated with scissors while removing tape around malfunctioning peripheral arterial line.

Cutaneous Fungal Outbreak Associated With Hospital Linens
April 1, 2014

Five critically-ill patients with hospital-associated Mucormycosis, specifically Rhizopus, all subsequently expired.

Wrong Size Tracheostomy Selection
March 1, 2014

A patient required increased oxygen, ventilator support, sedation and paralytics when the wrong-size cuffed tracheostomy tube was inserted.

Blind Pediatric NG Tube Placements
August 1, 2012

NG tube placement can lead to complications such as esophageal perforation, bronchopulmonary intubation, pneumothorax, hydrothorax, empyema, and pneumonia.


Diagnostic Safety

safety toolkit

A toolkit to address communication failures within the diagnostic process.

Patient Safety Alerts

Child Health PSO Patient Safety Action Alerts provide immediate notification of patient safety concerns for most  pediatric health care providers.