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.
Improving Communication in the Diagnostic Process
Child Health PSO has identified a safety concern related to communication failures in the diagnostic process.
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.
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.
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.
Silicone-Foley Catheter Balloon Rupture
Foley balloon rupture can lead to a urinary tract infection and/or sepsis requiring antibiotic therapy.
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.
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.
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.
Recognition of Retained Foreign Body: Button Battery
Button batteries remain conductive when ingested and can cause tissue erosion and significant damage if not removed in a timely manner.
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.
