TableĀ 5

Examples of changes implemented as a result of input from caregivers during mortality review process

Case descriptionOur response
Patient bled after bone marrow transplantSolution 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 channelRevised drug library options in intravenous pump and implemented hospital-wide drug safety competency
Multiple issues with transfers from outside hospitalsContinuing to re-evaluate strategies to improve transmission of information from other institutions
Formal inpatient hospice services not available to all patientsContinuing 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