In this section :
- Hospital harm is everyone鈥檚 concern
-
Hospital Harm Improvement Resource
- How to Use the Hospital Harm Measure for Improvement
- Learning from Harm
- General Patient Safety Quality Improvement and Measurement Resources
- Hypoglycemia: Introduction
- Aspiration Pneumonia: Introduction
- Delirium: Introduction
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Infusion, Transfusion and Injection Complications: Introduction
- Infusion, Transfusion and Injection Complications: Discharge Abstract Database
- Infusion, Transfusion and Injection Complications: Importance to Patients and Families
- Infusion, Transfusion and Injection Complications: Clinical and System Reviews, Incident Analyses
- Infusion, Transfusion and Injection Complications: Measures
- Infusion, Transfusion and Injection Complications: Success Stories
- Infusion, Transfusion and Injection Complications: References
- Medication Incidents: Introduction
- Obstetric Hemorrhage: Introduction
- Patient Trauma: Introduction
- Pneumonia: Introduction
- Pneumothorax: Introduction
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Post Procedural Infections: Introduction
- Post Procedural Infections: Discharge Abstract Database
- Post Procedural Infections: Importance to Patients and Families
- Post Procedural Infections: Clinical and Systems Reviews, Incident Analyses
- Post Procedural Infections: Measures
- Post Procedural Infections: Success Stories
- Post Procedural Infections: References
- Pressure Ulcer: Introduction
- Sepsis: Introduction
- UTI: Introduction
- Venous Thromboembolism: Introduction
- Wound Disruption: Introduction
- Obstetric Trauma: Introduction
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Procedure-Associated Shock: Introduction
- Procedure-Associated Shock: Discharge Abstract Database
- Procedure-Associated Shock: Importance to Patients and Families
- Procedure-Associated Shock: Clinical and System Review, Incident Analysis
- Procedure-Associated Shock: Measures
- Procedure-Associated Shock: Success Stories
- Procedure-Associated Shock: References
- Selected Serious Events: Introduction
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Electrolyte and Fluid Imbalance: Introduction
- Electrolyte and Fluid Imbalance: Discharge Abstract Database
- Electrolyte and Fluid Imbalance: Importance to Patients and Families
- Electrolyte and Fluid Imbalance: Clinical and System Reviews, Incident Analyses
- Electrolyte and Fluid Imbalance: Measures
- Electrolyte and Fluid Imbalance: Success Stories
- Electrolyte and Fluid Imbalance: References
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Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Introduction
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Discharge Abstract Database
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Importance to Patients and Families
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Clinical and System Reviews, Incident Analyses
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Measures
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): Success Stories
- Anemia 鈥� Hemorrhage (Health Care / Medication Associated Condition): References
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Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Introduction
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Discharge Abstract Database
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Importance to Patients and Families
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Clinical and System Reviews, Incident Analyses
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Measures
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): Success Stories
- Anemia 鈥� Hemorrhage (Procedure-Associated Conditions): References
- Birth Trauma: Introduction
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Device Failure: Introduction
- Device Failure: Discharge Abstract Database
- Device Failure: Importance to Patients and Families
- Device Failure: Clinical and System Reviews, Incident Analyses
- Device Failure Measures
- Device Failure: Success Stories
- Device Failure: References
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Infections due to Clostridium difficile, MRSA or VRE: Introduction
- Infections due to Clostridium difficile, MRSA or VRE: Discharge Abstract Database
- Infections due to Clostridium difficile, MRSA or VRE: Importance to Patients and Families
- Infections due to Clostridium difficile, MRSA or VRE: Surveillance, Outbreak Management
- Infections due to Clostridium difficile, MRSA or VRE: Clinical and System Reviews, Incident Analyses
- Infections due to Clostridium difficile, MRSA or VRE: Measures
- Infections due to Clostridium difficile, MRSA or VRE: Success Stories
- Infections due to Clostridium difficile, MRSA or VRE: References
- Laceration: Introduction
- Retained Foreign Body: Introduction
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Viral Gastroenteritis: Introduction
- Viral Gastroenteritis: Discharge Abstract Database
- Viral Gastroenteritis: Importance to Patients and Families
- Viral Gastroenteritis: Surveillance, Outbreak Management
- Viral Gastroenteritis: Clinical and System Reviews, Incident Analyses
- Viral Gastroenteritis: Measures
- Viral Gastroenteritis: Success Stories
- Viral Gastroenteritis: References
Device Failure: Clinical and System Reviews, Incident Analyses
Given the broad range of potential causes of device failure, in addition clinical and system reviews to identify latent causes and determine appropriate recommendations.
Occurrences of harm are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types and frequency of these occurrences.
- Use appropriate analytical methods to understand the contributing factors.
- Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
- Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resource Introduction.
If your review reveals that your cases of device failure are linked to specific processes or procedures, you may find these resources helpful:
- Canadian Agency for Drugs and Technologies in Health (CADTH)
- Canadian Patient Safety Institute
- Health Canada, Institute for Safe Medication Practices Canada, Health Standards Organization, Canadian Patient Safety Institute. Educational Support for Mandatory Reporting of Serious ADRs and MDIs by Hospitals. CPSI.
- Government of Canada
- Health Canada. About medical device problems. Government of Canada. Published January 24, 2020.
- Medical Devices Regulations (1998) SOR/98-282. Retrieved from
- Health Canada. Canadian Medical Devices Sentinel Network. Government of Canada. Published June 26, 2019.
- Health Canada. Medical device incidents. In: Adverse reactions, medical device incidents and health product recalls in Canada: 2019 summary report. Government of Canada. Published December 11, 2020.
- Health Canada. Adverse reactions, medical device incidents and health product recalls in Canada: 2019 summary report. Government of Canada. Published December 11, 2020.
- Medicines & Healthcare Products Regulatory Agency (MRHA) Medicines and Healthcare products Regulatory Agency - GOV.UK
- Medicines & Healthcare products Regulatory Agency (MHRA). Managing Medical Devices: Guidance for Health and Social Care Organisations. MHRA; 2021.
- Medicines & Healthcare products Regulatory Agency (MHRA). Devices in Practice: Checklists for Using Medical Devices. MHRA; 2014.
- National Institute for Health and Care Excellence (NICE)
- National Institute for Health and Care Excellence. Published guidance and advice. NICE Guidance.
- National Institute for Health and Care Excellence. Introducing techniques and medical devices. NICE Guidance: Local Practice. Published January 2013.
- National Institute for Health and Care Excellence. Medical Technologies Evaluation Programme. NICE guidelines.
- World Health Organization (WHO)
- World Health Organization. Medical devices. WHO Health Topics.
Device Failure
