Patient Safety Alerts & Safer Practice Notices

Healthcare providers and leaders need the most up-to-date information available so they can continue to provide high quality, safe care.

Patient Safety Notifications, including Patient Safety Alerts and Safer Practice Notices are developed and issued by AHS to inform healthcare providers about identified patient safety hazards and necessary actions to mitigate the risks.

There are a number of ways to address hazards to patient safety. If AHS staff and medical staff become aware of a patient safety hazard they believe should be considered for a Safer Practice Notice, Patient Safety Alert, or Patient Safety Memo, please contact your zone or provincial patient safety representative as appropriate to complete the intake process.

Document Status Date Issued / Updated Type
Ensuring safe use of Insulin pens and demonstration devices during patient education Active 2016-10-26 Safety Alert
Cisatracurium – Potential for 1000 fold error when using the Adult Critical Care Drug Library in BAXTER SIGMA SPECTRUM PUMPS Active 2016-05-17 Safety Alert
Updated - Safe use of Insulin Pens Active 2016-10-31 Safer Practice Notice
Preventing accidental ingestion of denture cleaners and other personal care or cleaning products Active 2016-08-31 Safer Practice Notice
Potential for retention of the SurgiFish® Viscera Retainer Active 2016-06-07 Safer Practice Notice
Restrict Medical Air Access for Patient Safety Active 2016-05-30 Safer Practice Notice
DO NOT USE Endotracheal tubes with subglottic suction (EVAC-ETT) in pediatrics Active 2016-03-28 Safer Practice Notice
Potential for Patient Harm when silencing pulse oximetry alarms or tones during procedures requiring sedation Active 2016-02-11 Safer Practice Notice
Alcohol Based Hand Rub Safety Active 2021-04-17 Safer Practice Notice
CADD®- Solis VIP Ambulatory Pumps - Risk for air embolism reduced with air-eliminating filter Active 2016-01-25 Safer Practice Notice
Choosing Correct Syringe Size - Medfusion Syringe Pump Active 2016-01-06 Safer Practice Notice
Safer Practice Notice - Safe Placement / Inflation of the King LT Airway Active 2015-10-19 Safer Practice Notice
Atypical Presentation of DKA with Sodium Glucose Co-transporter 2 (SGLT2) Inhibitors Active 2015-10-08 Safer Practice Notice
Safe Insulin Pump Therapy Active 2015-08-13 Safer Practice Notice
Preventing upper extremity injuries during transfers and repositioning Active 2016-08-10 Safer Practice Notice
Cerebrospinal Fluid (CSF) Sample Transport Active 2015-07-13 Safer Practice Notice
Identifying & Responding to Poisoning from illegally manufactured Non-Pharmaceutical Fentanyl Active 2015-05-14 Safer Practice Notice
Pre-Pouring Medications Active 2015-03-26 Safer Practice Notice
Alarm Default Settings-LIFEPAK Monitor/Defibrillator Active 2018-10-25 Safer Practice Notice
Use of Hydroxyethyl Starch (HES) Solutions (Voluven, Volulyte, or Pentaspan) in Critical Care Active 2018-09-07 Safer Practice Notice
Potential for Misconnections with Heated High Flow Oxygen Devices Active 2018-08-23 Safer Practice Notice
Bed Alarms-Safe Use and Configuration Active 2018-04-26 Safer Practice Notice
How to ensure ordering physicians receive laboratory results for patients discharged from inpatient units Active 2017-11-07 Safer Practice Notice
Medication Storage: Security and Safety Active 2014-10-14 Safer Practice Notice
Timely response and follow-up for patients exposed to blood and bodily fluids Active 2017-11-29 Safer Practice Notice
High doses of biotin interference with urinary and serum lab tests Active 2017-03-16 Safer Practice Notice
Transdermal Medication Patches Active 2017-03-14 Safer Practice Notice
Ceiling Lifts -Potential of Sling Straps Not Remaining on Carry Bar Active 2019-10-07 Safer Practice Notice
Safety Concerns regarding use of Home Glucose Monitoring Devices in the Acute Care Setting Active 2020-10-27 Safer Practice Notice
Adrenal Suppression in Asthmatic Children Resolved 2018-01-03 Safer Practice Notice
Carefusion Alaris PC Unit Model 8015 Battery Failure Resolved 2016-01-06 Safer Practice Notice
Clinoleic 20%, lipid emulsion used in Adult Parenteral Nutrition Resolved 2016-01-06 Safer Practice Notice
Cracked Roof Support-2007 Ford Ambulance Resolved 2016-01-06 Safer Practice Notice
EMS change of practice when using multi-dose injectable medications Resolved 2016-01-06 Safer Practice Notice
Endotracheal Tube Fastener Lip Pressure Necrosis Resolved 2016-06-22 Safer Practice Notice
Ensure the Safe Transfer of Patients Who Use Portable Oxygen Resolved 2019-04-01 Safer Practice Notice
Fall risk with incorrect sling attachment (Liko lift) Resolved 2018-05-10 Safer Practice Notice
False K+ Results with GEM® Premier 4000 Blood Gas Analyzers Resolved 2016-01-06 Safer Practice Notice
Hospira Gemstar New Software Notice Resolved 2016-01-06 Safer Practice Notice
Hospira GemSTAR Infusion Pumps: Potential for dose error at low flow rates Resolved 2016-01-06 Safer Practice Notice
Identifying IV Bags Used as Positioning Devices Resolved 2016-06-22 Safety Alert
Ineffective ventilation with Smart Bag® MO when diaphragm in patient valve is missing or placed incorrectly Resolved 2016-02-01 Safer Practice Notice
Instant Cold Packs-For SINGLE USE only Do Not Freeze Resolved 2016-01-06 Safer Practice Notice
Instant Hot Packs to be discontinued on pediatric patients Resolved 2016-01-06 Safer Practice Notice
Introduction of Power Injector Compatible Central Venous Catheters (CVCs) Resolved 2016-01-06 Safer Practice Notice
Look Alike Products: epiNEPHrine 1 mg/mL 1 mL ampoule and ePHEDrine 50 mg/mL 1 mL ampoule Resolved 2016-01-06 Safety Alert
New TaperGuard Evac ™ replaces Hi-Lo Evac Resolved 2016-01-06 Safer Practice Notice
Obstruction of oxygen flow possible when using humidifier bottles Resolved 2016-08-25 Safety Alert
Panda iRes Blender-Potential for Error Resolved 2016-01-06 Safer Practice Notice
Potassium Chloride 40 mmol in 100 mL SWI MINIBAGS will replace Potassium Chloride 40 mmol/20 mL vials for CRRT Resolved 2016-01-06 Safer Practice Notice
Potential for Glass-related Particles in FLOLAN® (epoprostenol sodium) Sterile Diluent and the Essential Use of a Filter with the Administration of the Reconstituted Product Resolved 2016-01-06 Safer Practice Notice
Proper Use and Maintenance of Ceiling Lifts Resolved 2016-01-06 Safer Practice Notice
Pump Failure Codes- Baxter Colleague Infusion Pumps Resolved 2016-01-06 Safer Practice Notice
Risk of error when using pre-filled normal saline syringes to reconstitute or dilute medications Resolved 2019-05-17 Safer Practice Notice
Shortage of Sterile Water & Sodium Chloride 0.9% for Injection Resolved 2019-02-27 Safer Practice Notice
Staff Response to Choking Events Resolved 2017-11-01 Safer Practice Notice
Survival Bracelets – present risk of self-harm or facilitating suicide Resolved 2016-06-22 Safer Practice Notice
Transportation of AHS Clients in Non –WC-19 Compliant Broada/Geri Chairs on Accessible Transportation Resolved 2016-06-28 Safer Practice Notice
Use Insulin Syringes when Administering or Preparing Intravenous Insulin Resolved 2019-04-01 Safety Alert
Misoprostol for Induction of Labour in the 3rd Trimester Active 2021-12-09 Safer Practice Notice