A patient was under frequent observation due to assessed high suicide risk. During one room check, staff saw that the patient had an improvised noose around his neck. The noose was made from window gasket pieces. Because of the frequent room checks and the difficulty in finding ligature tie-off points, this was discovered before the patient could harm himself. After review of the alternatives, benefits and hazards in their specific setting, the hospital replaced window gaskets with tamper-resistant sealants in the locked psychiatry ward’s patient rooms.
CHPSO recently completed an analysis of perinatal events
submitted to the database in the first quarter of 2018. There
were a total of 4,798 cases in the final dataset and the analysis
of these data revealed the following perinatal specific themes
A 34-year-old G1P0 (gravida 1 para 0 – first pregnancy, no
prior deliveries) arrives at her local hospital at 41 weeks
gestation for routine antenatal testing. The patient is a recent
immigrant to the US from a remote African village. While she
speaks English as a second language, she does so fluently.
She comes in on the dayshift for a nonstress test (NST). She
has had an uneventful prenatal course and has no risk factors
other than being post-dates (overdue).