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
-
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
-
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
-
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
-
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
-
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
-
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
- Device Failure: Introduction
-
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
- Laceration: Discharge Abstract Database
- Laceration: Importance to Patients and Families
- Laceration: Clinical and System Review Incident Analyses
- Laceration: Measures
- Laceration: Success Stories
- Laceration: References
- Retained Foreign Body: Introduction
-
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
Laceration: Clinical and System Review Incident Analyses
鈥婫iven the broad range of potential causes of laceration/puncture,听clinical and system reviews should be conducted to identify potential 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听conducting chart audits听补苍诲听analysis methods听are included in the听Hospital Harm Improvement Resources Introduction.
If your review reveals that your cases of laceration-puncture are linked to specific processes or procedures, you may find these resources helpful:
- Agency for Healthcare Research and Quality -听
- Toolkit for using the AHRQ quality indicators:听 How to improve hospital quality and safety. Selected best practices and suggestions for improvement PSI 15: Accidental puncture or laceration (Last reviewed 2017).听
- Association of periOperative Nurses (AORN) -听
- . (2019).听
- AORN .
- AORN Position statement on patient safety (2017).听
- Canadian Medical Protective Association -听
- Working with medical equipment - Reducing the risks. 2012. Available at:听
- Managing the medico-legal risks of placing a central line. 2011. Available at:听
- Canadian Patient Safety Institute听
- . (2016).
- National Health Services -听
- Chest drains: risks associated with the insertion of chest drains (2008). Archived 2010. Available at听听 听
- NICE 鈥撎�
- NICE interventional procedures guidance -听听
- Guidance on the use of ultrasound locating devices for placing central venous catheters (Published 2002; Reviewed
- 2016)听Snip 鈥� it Safety (2004). Available at听
- Robotic-assisted surgery: Focus on training and credentialing. 2014.听
- Distractions in the operating room.听 2014. Available at听
- Fetal lacerations associated with cesarean section (2004). Available at听
- The American College of Surgeons (ACS) -听
- Statement on patient safety in the operating room: team care (2018). Available at听
- Statement on distractions in the operating room (2016). Available at听
- (2016).听
- Revised statement on recommendations for use of real-time ultrasound guidance for placement of central venous catheters (2011). Available at听
- Revised statement on sharps safety (2016). Available at听
- The New England Journal of Medicine: Videos in Clinical Medicine 听
- Chest-Tube insertion (2007). Available at听
- Central venous catheter insertion:
- Ultrasound-guided internal jugular vein cannulation (2010). Available at听
- Placement of a femoral venous catheter (2008).听 Available at听
- Central Venous catheterization 鈥� subclavian vein (2007). Available at听
- Ultrasound-guided cannulation of the subclavian vein (2018). Available at听
Laceration
