Alert
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.
Alert
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.
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, pressure ulcers, blisters, scarring and wounds) in pediatric patients.
Alert
Fingertip Amputation
July 1, 2014
A neonate’s fingertip was amputated with scissors while removing tape around malfunctioning peripheral arterial line.
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 pneumonia.