Patient Safety Action Alerts

Patient Safety Action Alerts

Improving Identification of Patients at Risk for Human Trafficking

A Child Health Patient Safety Alert outlines health care professionals' roles in recognizing victims of labor and sex trafficking or exploitation.

April 25, 2022

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.

April 22, 2021

Wrong-site Surgeries/Procedures are Still Occurring When Site is Difficult to Mark

Patients experience wrong-site surgeries/procedures when surgical/procedural sites are difficult, or impossible, to mark or when patients/families refuse site marking.

April 17, 2019

Central Vascular Access Devices: From Orders to Insertion

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.

April 30, 2018

Procedural Mishaps: Retained Foreign Objects or Surgical Items

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

Dec. 20, 2017

Silicone-Foley Catheter Balloon Rupture

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

July 22, 2017

Sustained or Extended Release Medication Fill and Administration Errors

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

July 01, 2017

High-risk Pediatric Populations: Improving Safety and Reliability in Diabetes Care Management

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

June 28, 2017

Disinfection of Clinicians’ Personal Medical Devices to Prevent the Spread of Organisms

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

April 27, 2017

Thermal Injury

How to mitigate injuries from thermal devices (hot or cold) that can cause thermal injuries (severe burns, pressure ulcers, blisters, scarring and wounds) in pediatric patients.

Feb. 28, 2017
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About the PSO

The Child Health Patient Safety Organization enables children’s hospitals to share safety event information and experiences to accelerate the elimination of preventable harm.