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Ligature Risk from Window Weatherstripping
Patient safety alert

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.

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Perinatal Events Analysis Results
General lessons learned

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 and issues.

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Refusal to Permit Medical Treatment and the Power of Person-Centered Care

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).