Patient Safety Learning Advisories
Patient Safety Learning Advisories are de-identified summaries of a Critical Incident reviews to share lessons learned across the region.
Patient Safety Coordinators Contact Information or to Access Older PSLAs:
Tara Roberts or 204-903-5344
Pam Gunn or 204-903-7762
Policies & Resources
Patient Safety Learning Advisory (PSLA)
Tool for Guided Learning and Discussion
Also see Quality, Planning & Performance policies & forms
Fiscal PSLA Reports
April 1, 2024 to March 31, 2025
PSLA 2425-035 Missed STEMI
PSLA 2425-033 Plavix Prescribing Error
PSLA 2425-058 Fetal Demise
PSLA 2425-059 Fall with Fracture
PSLA 2425-039 Delay in Access to Care
PSLA 2425-016 Stage 3 Pressure Injury
PSLA 2425-024 Delay in Accessing Cardiac Angiogram
PSLA 2425-029 Delay in Testicular Torsion Diagnosis
PSLA 2425-047 Retained Surgical Item
PSLA 2425-079 Emergency Department Death
PSLA 2425-107 Retained Surgical Sponge
April 1, 2023 to March 31, 2024
PSLA 2324-143 Delay in Cancer Referral
PSLA 2324-120 Ruptured Ectopic Pregnancy
PSLA 2324-119 Delay in Diagnostic test to Rule out Cancer
PSLA 2324-118 Fall with Fracture
PSLA 2324-088 Pressure Injury
PSLA 2324-071 Fetal Demise
PSLA 2324-052 Management of Patient with Decompression Sickness
PSLA 2324-046 Patient Requiring Resuscitation following a Code White
PSLA 2324-020 Patient Suicide
PSLA 2324-013 Surgery Performed on the Wrong Body Part
April 1, 2022 to March 31, 2023
PSLA 2223-135 Patient Suicide
PSLA 2223-127 Delay in Proper Immobilization of Fracture contributing to Compartment Syndrome
PSLA 2223-104 Fall with Fracture
PSLA 2223-095 Suicide Attempt
PSLA 2223-092 Testicular Torsion
PSLA 2223-079 Fall with Fracture
PSLA 2223-070 Acetylcysteine (NAC) Overdose
PSLA 2223-060 Stillbirth
PSLA 2223-049 Leg Trauma/Sepsis
PSLA 2223-033 Potential burns to bilateral feet following an assisted tub bath/shower
PSLA 2223-024 Patient Fall
PSLA 2223-023 Fentanyl overdose
PSLA 2223-021 Pediatric Sepsis
April 1, 2021 to March 31, 2022
PSLA 2122-084 Pressure Injury
PSLA 2122-067 Compartment Syndrome
PSLA 2122-110 Mode of transportation (stretcher service) utilized for an unstable patient transfer
PSLA 2122-201 Intrahepatic Cholestasis of Pregnancy (ICP) Stillbirth
PSLA 2122-153 Healthcare Acquired COVID-19 Infection
PSLA 2122-135 Healthcare Acquired COVID-19 Infection
PSLA 2122-060 Healthcare Acquired COVID-19 Infection
PSLA 2122-068 Healthcare Acquired COVID-19 Infection
PSLA 2122-132 Healthcare Acquired COVID-19 Infection
PSLA 2122-168 Pressure Injury
PSLA 2122-029 Healthcare Acquired COVID-19 Infection
PSLA 2122-043 Healthcare Acquired COVID-19 Infection