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Risk Reference Sheets

Care

Mental Health

Inadequate Mental Health Facility and Space Design

Facility design is a key element of inpatient mental health safety and harm reduction. Designated inpatient stabilization and recovery programs as well as non-designated programs (e.g.,…

Risk Reference Sheets

Care

Obstetrics

Failure to Appreciate Deteriorating Pregnant and Postpartum Persons

Recent Canadian studies indicate a severe maternal morbidity rate of 16.1 per 1,000 deliveries for the period of 2012-16 and a maternal death rate of 8-9 per 100,000 for 1990 to 2013 …

Risk Reference Sheets

Care

Medications

Medication Adverse Events

Medication adverse events consist of both preventable medication incidents and adverse reactions (Agency for Healthcare Research and Quality, 2019). Medications are one of the most…

Risk Reference Sheets

Care

Mental Health

Death by Suicide and / or Attempts While In-Care

Suicidal behaviours are complex and multi-factorial which make them very challenging predictors of future conduct. This challenge impacts family, colleagues, and clinicians alike…

Risk Reference Sheets

Care

Deteriorating Patient

Failure to Appreciate Deteriorating Clients

The positive impact of early identification and management of client deterioration on clinical outcomes is well documented. The vast majority of catastrophic events are preceded by…

Risk Reference Sheets

Care

Obstetrics

Failure to Identify / Manage Neonatal Hyperbilirubinemia, Hypoglycemia, and / or Sepsis and Septic Shock

Neonatal hyperbilirubinemia and hypoglycemia are common metabolic issues within the first few days of life. While permanent brain injury in term infants is relatively rare, two causes of…

Risk Reference Sheets

Care

Diagnostic Errors

The spectrum of diagnosis-related claims spans a broad range of clinical outcomes in which it is alleged that the correct diagnosis for a client was not made in a timely manner…

Risk Reference Sheets

Care

Adverse Events

Mismanagement of Wounds and Pressure Injuries

Impaired wound healing is associated with a variety of contributing factors such as the presence of infection, pre-existing metabolic conditions, immunosuppression, and radiation…

Risk Reference Sheets

Care

Communication

Ineffective Communications in the Pre-Hospital Setting

In responding to a request for client transportation, effective communication can be challenging due to factors such as balancing time sensitive emergencies, multiple providers and…

Risk Reference Sheets

Care

Obstetrics

Mismanagement of Neonatal Resuscitation

Neonatal resuscitation after birth has become a significant liability exposure for healthcare organizations, practitioners, and resuscitation teams, particularly in cases where the…

Partnering to create the safest healthcare system

HIROC is not just a not-for-profit, we are a reciprocal. This means we are governed by our Subscribers – a group of over 800 diverse healthcare organizations across Canada. Together we share learnings and find ways to adapt to the changing nature of the industry.

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