Urgent action alerts on patient safety and public policy advocacy.

Recent Alerts

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 ...

Procedural Mishaps: Retained Foreign Objects or Surgical Items
December 20, 2017

Hospitals should assess standardized processes for potential gaps in accounting for all surgical items, especially new or altered ones, guidewires ...

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, ...

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 2, 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 ...