Improving Communication in the Diagnostic Process
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.
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.
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 pneumonia.