Examples of changes implemented as a result of input from caregivers during mortality review process
| Case description | Our response |
|---|---|
| Patient bled after bone marrow transplant | Solution of cells given during bone marrow transplant is now labelled indicating that heparin is included in mixture |
| Patient arrested: wrong drug in programmed intravenous pump channel | Revised drug library options in intravenous pump and implemented hospital-wide drug safety competency |
| Multiple issues with transfers from outside hospitals | Continuing to re-evaluate strategies to improve transmission of information from other institutions |
| Formal inpatient hospice services not available to all patients | Continuing to expand inpatient hospice services |
| Underdosing of an anticoagulant in a patient with a pulmonary embolus (not thought to be the cause of death) | Enhancement of decision support surrounding anticoagulant dosing |