Patient Safety Alerts & Safer Practice Notices

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

Patient Safety Alerts and Safer Practice Notices are developed and issued by AHS as a way to communicate urgent patient safety information to health-care providers.

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 or Patient Safety Alert please contact your zone or provincial patient safety representative as appropriate.

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