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Canada",[397],{"type":375,"attrs":398},{"href":399,"uuid":400,"anchor":53,"custom":401,"target":380,"linktype":381,"story":402},"/resources/never-events-for-hospital-care-in-canada","353ed3d3-5c43-4326-b261-bb8a60d5b02e",{},{"name":395,"id":403,"uuid":400,"slug":404,"url":405,"full_slug":405,"_stopResolving":386},113881462050616,"never-events-for-hospital-care-in-canada","resources/never-events-for-hospital-care-in-canada",{"text":407,"type":303},", three of the fifteen never events are associated with patient trauma during hospitalization:",{"type":305,"content":409},[410,416,422],{"type":308,"content":411},[412],{"type":15,"attrs":413,"content":414},{"textAlign":53},[415],{"text":314,"type":303},{"type":308,"content":417},[418],{"type":15,"attrs":419,"content":420},{"textAlign":53},[421],{"text":321,"type":303},{"type":308,"content":423},[424],{"type":15,"attrs":425,"content":426},{"textAlign":53},[427],{"text":328,"type":303},{"type":15,"attrs":429,"content":430},{"textAlign":53},[431],{"text":432,"type":303},"Additionally, evidence from the Canadian Adverse Event Study, indicates that adverse events classified as 'Other', including burns and falls was the sixth leading cause of an adverse event in Canada (Baker, Norton, et al, 2004).",{"type":360,"attrs":434,"content":436},{"level":435,"textAlign":53},3,[437],{"text":438,"type":303},"Falls",{"type":15,"attrs":440,"content":441},{"textAlign":53},[442],{"text":443,"type":303},"A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, the ground or other surface (e.g. mat). Injuries sustained by visitor slips, trips, and falls can result in significant harm and costs. Falls can be classified as:",{"type":305,"content":445},[446,453,460],{"type":308,"content":447},[448],{"type":15,"attrs":449,"content":450},{"textAlign":53},[451],{"text":452,"type":303},"Anticipatory (patients exhibit clinical signs that contribute to increased falls risk),",{"type":308,"content":454},[455],{"type":15,"attrs":456,"content":457},{"textAlign":53},[458],{"text":459,"type":303},"Unanticipated (physiological falls that cannot be predicted before first occurrence) and",{"type":308,"content":461},[462],{"type":15,"attrs":463,"content":464},{"textAlign":53},[465],{"text":466,"type":303},"Accidental (result of mishaps) ",{"type":15,"attrs":468,"content":469},{"textAlign":53},[470],{"text":471,"type":303},"Anticipated falls can be prevented through screening for falls risk factors, communication and in-depth assessment and implementation of targeted prevention strategies (HIROC 2016). ",{"type":15,"attrs":473,"content":474},{"textAlign":53},[475],{"text":476,"type":303},"A range of risk factors (>400) have been identified as influencing whether individuals are likely to fall. The BBSE MODEL of fall-related risk factors identifies biological (intrinsic), behavioural, social and economic and environmental (extrinsic) risk factors. The more risk factors an individual has, the greater the risk of falling (Safer Healthcare Now! 2013; RNAO 2017).",{"type":15,"attrs":478,"content":479},{"textAlign":53},[480],{"text":481,"type":303},"Falls may cause considerable physical harm, including fractures, soft tissue injuries, haematomas, lacerations and pressure sores due to subsequent immobility; as well as psychological distress such as fear of falling and humiliation and potentially resulting in chronic pain, loss of independence, reduced quality of life, and even death (Johal 2009; Public Health Agency of Canada 2014; Accreditation Canada, CIHI, CPSI 2014). ",{"type":15,"attrs":483,"content":484},{"textAlign":53},[485],{"text":486,"type":303},"Studies in acute care settings show that fall rates range from 1.3 to 8.9 falls per 1,000 patient days, with higher rates in units that focus on geriatric care, neurology, and rehabilitation (Oliver 2010). Research shows that close to one-third of falls can be prevented (Ganz, et al. 2013/2018).",{"type":360,"attrs":488,"content":489},{"level":435,"textAlign":53},[490],{"text":491,"type":303},"Burns/Scald",{"type":15,"attrs":493,"content":494},{"textAlign":53},[495],{"text":496,"type":303},"Burns to skin (or other organs) is a function of both temperature and duration. Even moderate heat applied for a long duration is capable of producing burns. There are three key conditions that predispose patients to burns including insensitivity to pain/temperature, unresponsiveness, or inability to communicate. In addition, impaired ability for the vasculature to help dissipate heat from the skin may predispose a patient to a burn (Patient Safety Solutions 2010).",{"type":15,"attrs":498,"content":499},{"textAlign":53},[500],{"text":501,"type":303},"Hospital emergency rooms and operating rooms contain the three primary elements needed to ignite a fire:",{"type":305,"content":503},[504,511,518],{"type":308,"content":505},[506],{"type":15,"attrs":507,"content":508},{"textAlign":53},[509],{"text":510,"type":303},"An oxidizer (anesthesia products such as oxygen and nitrous oxide).",{"type":308,"content":512},[513],{"type":15,"attrs":514,"content":515},{"textAlign":53},[516],{"text":517,"type":303},"Fuel (surgical drapes, alcohol swabs, etc.).",{"type":308,"content":519},[520],{"type":15,"attrs":521,"content":522},{"textAlign":53},[523],{"text":524,"type":303},"An ignition source (lasers, electrosurgical devices such as a cautery knife, etc.)",{"type":15,"attrs":526,"content":527},{"textAlign":53},[528],{"text":529,"type":303},"Fires that ignite in or around a patient during surgery are a real danger and are especially devastating if open oxygen sources are present during surgery of the head, face, neck, and upper chest (ECRI 2016).",{"type":15,"attrs":531,"content":532},{"textAlign":53},[533],{"text":534,"type":303},"A search of patient safety reporting/alert systems revealed that the potential causes of accidental burns include:",{"type":305,"content":536},[537,544,551,558,565,572,579,586,593],{"type":308,"content":538},[539],{"type":15,"attrs":540,"content":541},{"textAlign":53},[542],{"text":543,"type":303},"A hot towel prepared in a plastic bag coming in contact with patient's body during bed-bath (Japan Council for Quality Health Care 2010).",{"type":308,"content":545},[546],{"type":15,"attrs":547,"content":548},{"textAlign":53},[549],{"text":550,"type":303},"Use of a hot water bottle (Japan Council for Quality Health Care 2010).",{"type":308,"content":552},[553],{"type":15,"attrs":554,"content":555},{"textAlign":53},[556],{"text":557,"type":303},"Fire and the use of Alcohol-based hand cleansers (New South Wales Department of Health 2007).",{"type":308,"content":559},[560],{"type":15,"attrs":561,"content":562},{"textAlign":53},[563],{"text":564,"type":303},"Water temperature too hot during bathing (Japan Council for Quality Health Care 2007).",{"type":308,"content":566},[567],{"type":15,"attrs":568,"content":569},{"textAlign":53},[570],{"text":571,"type":303},"Vaseline and treatment with oxygen (European Union Network for Patient Safety 2011).",{"type":308,"content":573},[574],{"type":15,"attrs":575,"content":576},{"textAlign":53},[577],{"text":578,"type":303},"Heat therapy such as heating pads or hot packs (Data snapshot 2009).",{"type":308,"content":580},[581],{"type":15,"attrs":582,"content":583},{"textAlign":53},[584],{"text":585,"type":303},"Food preparation and hot liquid spills (Data snapshot 2009).",{"type":308,"content":587},[588],{"type":15,"attrs":589,"content":590},{"textAlign":53},[591],{"text":592,"type":303},"Burns Caused by the Tip of a Light Source Cable during Surgery (Japan Council for Quality Health Care 2012).",{"type":308,"content":594},[595],{"type":15,"attrs":596,"content":597},{"textAlign":53},[598],{"text":599,"type":303},"Risk of skin-prep related fire in operating theatres (National Health Service Commissioning Board 2012).",{"type":360,"attrs":601,"content":602},{"level":435,"textAlign":53},[603],{"text":604,"type":303},"Asphyxiation",{"type":15,"attrs":606,"content":607},{"textAlign":53},[608],{"text":609,"type":303},"Asphyxia is severe hypoxia leading to hypoxemia and hypercapnia, loss of consciousness, and, if not corrected, death. There are many circumstances that can induce asphyxia; some of the more common causes are drowning, electrical shock, aspiration of vomitus, lodging of a foreign body in the respiratory tract, inhalation of toxic gas or smoke, and poisoning (Mosby's Medical Dictionary 2009). A search of patient safety reporting/alert systems revealed that the potential causes of iatrogenic asphyxia include:",{"type":305,"content":611},[612,619,626,633,640,647],{"type":308,"content":613},[614],{"type":15,"attrs":615,"content":616},{"textAlign":53},[617],{"text":618,"type":303},"Restraints; (Registered Nurses' Association of Ontario 2017).",{"type":308,"content":620},[621],{"type":15,"attrs":622,"content":623},{"textAlign":53},[624],{"text":625,"type":303},"Positional asphyxia. This occurs when body position prevents adequate gas exchange, such as from upper airway obstruction or a limitation in chest wall expansion (Segen's Medical Dictionary 2012).",{"type":308,"content":627},[628],{"type":15,"attrs":629,"content":630},{"textAlign":53},[631],{"text":632,"type":303},"Strangulation (Registered Nurses' Association of Ontario 2012).",{"type":308,"content":634},[635],{"type":15,"attrs":636,"content":637},{"textAlign":53},[638],{"text":639,"type":303},"Rail entrapment - when caught, stuck, wedged, or trapped between the mattress/bed and the bed rail, between bed rail bars, between a commode and rail, between the floor and rail, or between the headboard and rail (U.S. Food and Drug Administration 2018).",{"type":308,"content":641},[642],{"type":15,"attrs":643,"content":644},{"textAlign":53},[645],{"text":646,"type":303},"Accidental ingestion of fluid/food thickening powder (NHS 2015).",{"type":308,"content":648},[649],{"type":15,"attrs":650,"content":651},{"textAlign":53},[652],{"text":653,"type":303},"Traumatic intubation (Pazannin et al. 2008).",{"type":360,"attrs":655,"content":656},{"level":362,"textAlign":53},[657],{"text":658,"type":303},"Importance to Patients and Families",{"type":15,"attrs":660,"content":661},{"textAlign":53},[662],{"text":663,"type":303},"In hospitals, patient accidents may cause unintended injuries or death. With the right interventions, proper communication with patients and families, and appropriate reporting and related learning, patient accidents can be prevented over the long-term.",{"type":360,"attrs":665,"content":666},{"level":362,"textAlign":53},[667],{"text":668,"type":303},"Patient Story",{"type":360,"attrs":670,"content":672},{"level":671,"textAlign":53},4,[673],{"text":674,"type":303},"When providing care, put the patient into perspective",{"type":15,"attrs":676,"content":677},{"textAlign":53},[678],{"text":679,"type":303},"How did 80-year old Ambrose Wald fall out of a hospital chair specifically designed to stop patients from falls? It's a question to which his daughter Irene Wald, a nurse of almost 35 years, has never received an answer. (Canadian Patient Safety Institute 2013)","simple-richtext","wysiwyg-program",{"_uid":683,"items":684,"title":984,"component":985,"description":986},"9e5befbf-06c9-4f16-9ebf-b0f37018e5a4",[685],{"_uid":686,"title":687,"ctaLeft":688,"ctaRight":689,"component":690,"columnLeft":691,"columnRight":715},"4bef2000-2854-460d-9022-8e0436e83838","Expand to see a full list of resources",[],[],"accordion-item-columns",{"type":12,"content":692},[693],{"type":15,"attrs":694,"content":695},{"textAlign":53},[696,703,710],{"text":697,"type":303,"marks":698},"To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. 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",{"text":804,"type":303,"marks":805},"https://www.ecri.org/Accident_Investigation/Pages/Surgical-Fire-Prevention.aspx",[806],{"type":375,"attrs":807},{"href":804,"uuid":53,"anchor":53,"custom":808,"target":737,"linktype":738},{},{"type":308,"content":810},[811,822],{"type":15,"attrs":812,"content":813},{"textAlign":53},[814,816],{"text":815,"type":303},"Healthcare Insurance Reciprocal of Canada (HIROC). ",{"text":817,"type":303,"marks":818},"https://www.hiroc.com",[819],{"type":375,"attrs":820},{"href":817,"uuid":53,"anchor":53,"custom":821,"target":737,"linktype":738},{},{"type":305,"content":823},[824,837,844],{"type":308,"content":825},[826],{"type":15,"attrs":827,"content":828},{"textAlign":53},[829,831],{"text":830,"type":303},"Risk Reference Sheets. Healthcare Acquired Burns. 2020. 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",{"text":859,"type":303,"marks":860},"www.Nice.org.uk",[861],{"type":375,"attrs":862},{"href":863,"uuid":53,"anchor":53,"custom":864,"target":737,"linktype":738},"http://www.Nice.org.uk",{},{"type":305,"content":866},[867],{"type":308,"content":868},[869],{"type":15,"attrs":870,"content":871},{"textAlign":53},[872,874],{"text":873,"type":303},"Falls in older people: Assessing risk and prevention. NICE guidelines. 2013. ",{"text":875,"type":303,"marks":876},"http://www.nice.org.uk/guidance/cg161/chapter/1-recommendations",[877],{"type":375,"attrs":878},{"href":875,"uuid":53,"anchor":53,"custom":879,"target":737,"linktype":738},{},{"type":308,"content":881},[882,893],{"type":15,"attrs":883,"content":884},{"textAlign":53},[885,887],{"text":886,"type":303},"NHS Institute for Innovation and Improvement. 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",{"text":910,"type":303,"marks":911},"https://rnao.ca",[912],{"type":375,"attrs":913},{"href":910,"uuid":53,"anchor":53,"custom":914,"target":737,"linktype":738},{},{"type":305,"content":916},[917,930,943],{"type":308,"content":918},[919],{"type":15,"attrs":920,"content":921},{"textAlign":53},[922,924],{"text":923,"type":303},"Preventing Falls and Reducing Injury from Falls, Fourth Edition. 2017. ",{"text":925,"type":303,"marks":926},"https://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries",[927],{"type":375,"attrs":928},{"href":925,"uuid":53,"anchor":53,"custom":929,"target":737,"linktype":738},{},{"type":308,"content":931},[932],{"type":15,"attrs":933,"content":934},{"textAlign":53},[935,937],{"text":936,"type":303},"Promoting Safety: Alternative Approaches to the Use of Restraints. 2012. ",{"text":938,"type":303,"marks":939},"https://rnao.ca/bpg/guidelines/promoting-safety-alternative-approaches-use-restraints",[940],{"type":375,"attrs":941},{"href":938,"uuid":53,"anchor":53,"custom":942,"target":737,"linktype":738},{},{"type":308,"content":944},[945],{"type":15,"attrs":946,"content":947},{"textAlign":53},[948,950],{"text":949,"type":303},"Sustainability and the Prevention of Falls and Fall Injuries in the Older Adult. 2014. ",{"text":951,"type":303,"marks":952},"https://rnao.ca/bpg/get-involved/acpf/executive-summaries/giselle-talledo-hastie",[953],{"type":375,"attrs":954},{"href":951,"uuid":53,"anchor":53,"custom":955,"target":737,"linktype":738},{},{"type":308,"content":957},[958,969],{"type":15,"attrs":959,"content":960},{"textAlign":53},[961,963],{"text":962,"type":303},"Royal College of Physicians (UK)l. 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Organizations need to:",{"type":1013,"attrs":1014,"content":1016},"ordered_list",{"order":1015},1,[1017,1024,1031,1038],{"type":308,"content":1018},[1019],{"type":15,"attrs":1020,"content":1021},{"textAlign":53},[1022],{"text":1023,"type":303},"Measure and monitor the types and frequency of these occurrences.",{"type":308,"content":1025},[1026],{"type":15,"attrs":1027,"content":1028},{"textAlign":53},[1029],{"text":1030,"type":303},"Use appropriate analytical methods to understand the contributing factors.",{"type":308,"content":1032},[1033],{"type":15,"attrs":1034,"content":1035},{"textAlign":53},[1036],{"text":1037,"type":303},"Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.",{"type":308,"content":1039},[1040],{"type":15,"attrs":1041,"content":1042},{"textAlign":53},[1043],{"text":1044,"type":303},"Have mechanisms in place to mitigate consequences of harm when it occurs.",{"_uid":1046,"items":1047,"title":1083,"component":1084,"description":1085},"3299f4e2-5248-4c98-ac38-ed0ab4e064a2",[1048,1059,1067,1075],{"_uid":1049,"image":1050,"title":1054,"component":1055,"description":1056},"db9fdb12-8e66-4274-a99b-276e7c441dc5",{"id":1051,"alt":16,"name":16,"focus":16,"title":16,"source":16,"filename":1052,"copyright":16,"fieldtype":289,"meta_data":1053,"is_external_url":277},119537678778928,"https://a-ca.storyblok.com/f/850807391887861/600x600/c301964117/checkmark-icon.png",{},"You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.","small-text-image-item",{"type":12,"content":1057},[1058],{"type":15},{"_uid":1060,"image":1061,"title":1063,"component":1055,"description":1064},"3eb5659d-5a90-4d22-9a12-a5a0b9a55a9a",{"id":1051,"alt":16,"name":16,"focus":16,"title":16,"source":16,"filename":1052,"copyright":16,"fieldtype":289,"meta_data":1062,"is_external_url":277},{},"Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.",{"type":12,"content":1065},[1066],{"type":15},{"_uid":1068,"image":1069,"title":1071,"component":1055,"description":1072},"97ccaf2a-b041-44d0-979e-3aff3e35571c",{"id":1051,"alt":16,"name":16,"focus":16,"title":16,"source":16,"filename":1052,"copyright":16,"fieldtype":289,"meta_data":1070,"is_external_url":277},{},"Whenever possible, use measures you are already collecting for other programs.",{"type":12,"content":1073},[1074],{"type":15},{"_uid":1076,"image":1077,"title":1079,"component":1055,"description":1080},"0417ee0d-76a8-4183-8e36-8f8dacbaf3eb",{"id":1051,"alt":16,"name":16,"focus":16,"title":16,"source":16,"filename":1052,"copyright":16,"fieldtype":289,"meta_data":1078,"is_external_url":277},{},"Try to include both process and outcome measures in your measurement scheme.",{"type":12,"content":1081},[1082],{"type":15},"Measures","small-text-image",{"type":12,"content":1086},[1087],{"type":15,"attrs":1088,"content":1089},{"textAlign":53},[1090],{"text":1091,"type":303},"Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:",{"_uid":1093,"items":1094,"title":1131,"component":985,"description":1132},"dadb33a7-4880-4a5e-8a14-c2b4de6e7b8a",[1095],{"_uid":1096,"title":1097,"ctaLeft":1098,"ctaRight":1099,"component":690,"columnLeft":1100,"columnRight":1117},"31e457d3-6058-4d7e-a4b9-81feb110d495","Selection Criteria",[],[],{"type":12,"content":1101},[1102,1107,1112],{"type":15,"attrs":1103,"content":1104},{"textAlign":53},[1105],{"text":1106,"type":303},"M96.6",{"type":15,"attrs":1108,"content":1109},{"textAlign":53},[1110],{"text":1111,"type":303},"S00–T32",{"type":15,"attrs":1113,"content":1114},{"textAlign":53},[1115],{"text":1116,"type":303},"T71",{"type":12,"content":1118},[1119],{"type":15,"attrs":1120,"content":1121},{"textAlign":53},[1122,1124,1129],{"text":1123,"type":303},"Identified as diagnosis type (2) ",{"text":1125,"type":303,"marks":1126},"not in a diagnosis cluster AND",[1127],{"type":1128},"bold",{"text":1130,"type":303}," U98.20*","Discharge 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Preventing falls: From evidence to improvement in Canadian Health Care. Ottawa, ON: CIHI; 2014. ",{"text":1485,"type":303,"marks":1486},"https://accreditation.ca/sites/default/files/falls-joint-report-2014-en.pdf",[1487],{"type":375,"attrs":1488},{"href":1485,"uuid":53,"anchor":53,"custom":1489,"target":737,"linktype":738},{},{"type":15,"attrs":1491},{"textAlign":53},{"type":308,"content":1493},[1494,1505],{"type":15,"attrs":1495,"content":1496},{"textAlign":53},[1497,1499],{"text":1498,"type":303},"Baker GR, Norton P. Patient safety and healthcare error in the Canadian healthcare system: A systematic review and analysis of leading practices in Canada with reference to key initiatives elsewhere. A Report to Health Canada. Ottawa: Health Canada; 2002. ",{"text":1500,"type":303,"marks":1501},"http://www.hc-sc.gc.ca/hcs-sss/pubs/qual/2001-patient-securit-rev-exam/index-eng.php",[1502],{"type":375,"attrs":1503},{"href":1500,"uuid":53,"anchor":53,"custom":1504,"target":737,"linktype":738},{},{"type":15,"attrs":1506},{"textAlign":53},{"type":308,"content":1508},[1509,1522],{"type":15,"attrs":1510,"content":1511},{"textAlign":53},[1512,1514,1520],{"text":1513,"type":303},"Canadian Patient Safety Institute (CPSI).  ",{"text":395,"type":303,"marks":1515},[1516],{"type":375,"attrs":1517},{"href":399,"uuid":400,"anchor":53,"custom":1518,"target":737,"linktype":381,"story":1519},{},{"name":395,"id":403,"uuid":400,"slug":404,"url":405,"full_slug":405,"_stopResolving":386},{"text":1521,"type":303},". Edmonton, Alberta; 2015.",{"type":15,"attrs":1523},{"textAlign":53},{"type":308,"content":1525},[1526,1537],{"type":15,"attrs":1527,"content":1528},{"textAlign":53},[1529,1531],{"text":1530,"type":303},"Canadian Patient Safety Institute (CPSI). 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Edmonton, Alberta; 2013.",{"type":15,"attrs":1554},{"textAlign":53},{"type":308,"content":1556},[1557,1568],{"type":15,"attrs":1558,"content":1559},{"textAlign":53},[1560,1562],{"text":1561,"type":303},"Data snapshot: Iatrogenic burn injuries. Pennsylvania Patient Safety Advisory. 2009; 6 (1): 36. ",{"text":1563,"type":303,"marks":1564},"http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Mar6%281%29/Pages/36.aspx",[1565],{"type":375,"attrs":1566},{"href":1563,"uuid":53,"anchor":53,"custom":1567,"target":737,"linktype":738},{},{"type":15,"attrs":1569},{"textAlign":53},{"type":308,"content":1571},[1572,1582],{"type":15,"attrs":1573,"content":1574},{"textAlign":53},[1575,1577],{"text":1576,"type":303},"ECRI Institute. Surgical fire resources. Plymounth, PA; 2016. 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Agency for Healthcare Research and Quality. Published January 2013. Updated July 2018. ",{"text":1607,"type":303,"marks":1608},"http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html",[1609],{"type":375,"attrs":1610},{"href":1607,"uuid":53,"anchor":53,"custom":1611,"target":737,"linktype":738},{},{"type":15,"attrs":1613},{"textAlign":53},{"type":308,"content":1615},[1616,1627],{"type":15,"attrs":1617,"content":1618},{"textAlign":53},[1619,1621],{"text":1620,"type":303},"Healthcare Insurance Reciprocal of Canada (HIROC). Risk Reference Sheets. Patient Falls (2016). 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Burn caused by a bed-bath towel. Medical Safety Information. 2010; 46. ",{"text":1652,"type":303,"marks":1653},"http://www.med-safe.jp/pdf/No.46_MedicalSafetyInformation.pdf",[1654],{"type":375,"attrs":1655},{"href":1652,"uuid":53,"anchor":53,"custom":1656,"target":737,"linktype":738},{},{"type":15,"attrs":1658},{"textAlign":53},{"type":308,"content":1660},[1661,1672],{"type":15,"attrs":1662,"content":1663},{"textAlign":53},[1664,1666],{"text":1665,"type":303},"Japan Council for Quality Health Care. Burn during assisted bathing. Medical Safety Information. 2007; 5. 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