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

Resources

Alert
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.

Alert
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.

Alert
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, ...

Alert
Silicone-Foley Catheter Balloon Rupture
July 22, 2016

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

Alert
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.

Alert
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.

Alert
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.

Alert
Sustained or Extended Release Medication Fill and Administration Errors
July 2, 2014

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

Alert
Fingertip Amputation
July 1, 2014

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

Alert
Cutaneous Fungal Outbreak Associated With Hospital Linens
April 1, 2014

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

Alert
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.

Alert
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 ...

Contact

Patient Safety Alerts

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

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