Patient Safety Learning Advisories
Patient Safety Learning Advisories (PSLAs) are factual summaries of critical incidents or patient safety reviews. PSLAs are used when healthcare learning opportunities (system learning) are identified which may decrease the risk of similar occurrences or prevent future patient harm.
PSLAs are developed following completion of the Critical Incident review so the timeline between an individual event and the completion of a PSLA may vary and will not include information related to CIs where a review is in progress. Each of these learnings may cover multiple events. Any immediate safety risks identified through the CI investigation would be shared with staff in real time, through Patient Safety Huddles or Patient Safety Alerts.
These are shared broadly with patients/families and healthcare providers to encourage system learning, and to improve safety and quality of health services.
Action: Review the PSLAs and reflect on how this information could be used in your work or care area to reduce risks to patients/clients/residents.
| Patient Safety Learning Advisory | Keywords |
|---|---|
| Delay in Angiogram | Cardiac care, angiogram |
| Deterioration of a Pressure Injury After Discharge | Pressure injury, information transfer, Kardex |
| Development of Compartment Syndrome | Compartment syndrome, immobilization of fracture, transfer delays |
| Elopement | Elopement, death, pass, leave pass |
| Failure to Recognize Deteriorating Health Status | Lab results, creatinine, deterioration, communication, shift handover, information transfer, NEWS |
| Fall from Bed Causing Fracture | Fall, fracture, documentation, shift handover, communication, fall mat |
| Injury During Positioning of Wheelchair | Fracture, table, equipment, wheelchair, seated, accessibility |
| Medical Devices Causes Pressure Injury | Pressure injury, medical device, feeding tube |
| Pressure Injury Deterioration While in Care | Pressure injury, wound, stage 3, pressure-relieving device, wheelchair, communication, shift handover |
| Surgery Performed on the Wrong Body Site | Surgery, wrong site, surgical safety checklist, surgical site |
| Wrong Medical Device Inserted During Procedure | Surgery, surgical procedure, wrong device, medical device, surgical safety checklist, equipment storage, training, delegation |