During the spring of 2004, in the Calgary Health Region (CHR) two critical incidents occurred involving patients receiving continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). The outcome of these events resulted in the sudden death of both patients.The Department of Critical Care Medicine's Patient Safety and Adverse Events Team (PSAT), utilized the Healthcare Failure Mode and Effect Analysis (HFMEA) tool to review the process and conditions surrounding the ordering and administration of potassium chloride (KCl) and potassium phosphate (KPO 4 ) in our ICUs.The HFMEA tool and the multidisciplinary team structure provided a solid framework for systematic analysis and prioritization of areas for improvement regarding the use of intravenous, high-concentration KCL and KPO 4 in the ICU.
No abstract
While the Protection Branch is, primarily, an enforcement arm of the Service, the Fish Culture Development Branch (stafTed by biologists,, engineers and technicians) is an investigative arm designed to* deal with ad hoc problems affecting the resource and to recommend remedial and development measures based on the best information available from research sources. The Fish Culture Branch (in Newfoundland) concerns itself primarily with the freshwater phase of anadromous fishes as well as with purely freshwater fishes. This latter function was not assumed until 1956 when, by agreement between the two governments, management and investigation of freshwater species was relinquished by the Provincial Government and assumed by the Department of Fisheries of Canada. Because the Fish Culture Development Branch in 1956 was still in its formative stages, and because of the necessity to emphasize matters relating to anadromous salmon, it was unable to do other than very sporadic work in the field of purely freshwater fishes-usually incidental to the main program on Atlantic salmon. Thus in 1955, while doing a survey of obstructions to salmon in the Humber River, it was possible to "sound" Adies Lake and Deer Lake. Adies Lake, it was found, though local report had it "bottomless", had a maximum depth of some 48 feet. It was also determined to have a good population of brook trout but no other species (i.e. other than sea-run salmon) were located. Deer Lake, a much larger body of water, was sounded though not in great detail. The deepest water located was in the order of 325 feet. No population sampling was carried out on either lake, except by anghng. Because of the lack of information on inland waters, and because Departmental staff could not be seconded to lake work, it was decided in 1959 to request personnel of the Department of Ichthyology and Herpetology of the Royal Ontario Museum to make a brief survey of the species present in freshwater areas of the Island. This was done and Drs. Scott and Crossman carried out an investigation during July 1960. It is as a result of that survey that the report to follow has been written. This survey extended significantly knowledge of the species in freshwater and estuarine areas as is brought out in the main report. Beginning in 1961, and continued in 1962, it was possible for the Department of Fisheries in the Newfoundland area to begin initial study of major freshwater areas and their fish populations. By the end of 1962 ten representative lakes had received prehminary examination, primarily in the nature of collecting morphometric data and sampling of fish populations. Lesser amounts of other limnological data were also collected. Although much information gathered during these surveys has not yet been analysed or reported on, it can be generally said that most large lakes probably have a relatively low productive 7 G7727-8-2^ for the interest in it now-to make possible wise exploitation of what exists and, where feasible, to develop its productive capacity to even higher levels.
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