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Doctor learning imageOver the month of February, UHNews will showcase the lessons learned from four recent incidents to communicate how a wide variety of risks can be avoided, including:

  1. Exposing patient information on paper
  2. Administering the wrong dose of medication
  3. Losing unencrypted electronic devices
  4. Mixing up compressed air and oxygen

Case study: Patient info lost

As part of her usual practice, an OR nurse printed off the entire OR patient list for the next day to review each case. While on her way to see a physician to review a case, she stopped in the cafeteria to have lunch with a few colleagues.

She didn't notice when the list fell out of her pocket and a couple placed it in a garbage can. When the nurse finally noticed that the list was gone, she contacted her lunch mates, secured the garbage and recycling bins in the cafeteria area and sorted through each one until the list was found. Luckily, she found the list and no information was lost.


What was the risk?

That the personal health in​formation of 90 patients could have been inappropriately disclosed and used—a violation of the Personal Health Information Protection Act that requires remedial action and notification of all affected patients.


What would have happened if the paper had not been found?

Under the law, the hospital must tell a patient when their personal health information is lost, stolen or inappropriately accessed. This may create a risk of harm to the patient, ​as well as being a cause of distress. Typically, the person responsible for the incident is tasked with notifying patients and responding to their questions and distress. The nurse would have had to coordinate with the Privacy Office before sitting down with 90 patients to explain to them what happened.


Remember, report incidents ASAP!

Securing and searching the bins meant the paper was found and the nurse avoided the time-consuming of notifying all the patients, and both the nurse and the patients avoided a stressful conversation. To avoid this situation altogether, leave papers in a secure location.


Next week: Part two

What happens when the wrong dose of me​​dication is administered?

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