RISK ALERT. ISSUE 49 APR 2018 A Risk Management Newsletter for Hospital Authority Healthcare Professionals

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1 RISK ALERT ISSUE 9 APR 08 A Risk Management Newsletter for Hospital Authority Healthcare Professionals in this issue Sentinel Events (SEs) (Q 07) Retained instruments / material Patient suicide Wrong patient/ part Serious Untoward Events (SUEs) (Q 07) Local Sharing Procedure Safety Policies Opening Message My humble experience with handling clinical incident can be summarized by 6Cs: critical, candid, concise, connecting, caring and communication. When dissecting a clinical incident, one must adopt a critical, candid but nonpunitive attitude. There have been too many Root Cause Analysis (RCA) reports merely putting down various root causes and suggestions of practical improvement measures. However, to be candid and critical, we should identify critical suboptimal steps before implementing relevant mitigation measures to effectively eliminate or control the risk. Take guide wire retention after central line insertion as an example. It may be easy to put down suggestions such as enhanced alertness and more senior rank staff involvement. Since similar incidents recur despite such suggestions, it would therefore be more constructive if we could establish critical check points like counting of guide wires and exchange of final suture needle after return of guide wire. One may argue or wonder why even the above improvement measures had failed to prevent guide wire retention. We now know it is not because these measures are not effective but because of staff noncompliance. For a RCA report to be meaningful, it must be concise. Our staff is already overwhelmed with hundreds of documents, so any recommended improvement measures in the RCA report must be relevant and concise, practical and workable. The RCA report must also be connecting. Since it is our frontline colleagues who need to implement these measures, so we have to be connected to them rather than writing up reports in office. Lastly, in handling incidents, we should always maintain a caring and empathetic attitude. All parties including the patient, families and involved staff need to be supported. There is nothing to replace effective communication because at the end, health care is a human business. Dr K Y PANG Chief Of Service (Neurosurgery) Pamela Youde Nethersole Eastern Hospital

2 SE & SUE Statistics Distribution of SE in the last four quarters Distribution of SUE in the last four quarters Medication error Q 07 Q Patient misidentification Q3 07 Q 07 Wrong patient/part Retained instruments/material Inpatient suicide Maternal morbidity Gas embolism ABO incompatibility Q 07 0 Q 07 Q3 07 Q 07 Wrong infant/ abduction Sentinel Events Retained Instruments / Material Retained guide wire after double lumen catheter insertion A patient with cervical cord transverse myelitis was prescribed plasmapheresis as her disease did not respond to pulse steroid treatment. Double lumen catheter insertion was required for plasmapheresis. During catheter insertion, pre-procedural checking & TIME OUT were performed. During post-procedural checking, the guide wire was not found. However, the box for Guide wire is removed was ticked in the post-procedural checking list. On the next day, a retained guide wire was noted on Chest X-Ray. The guide wire was removed intact under image guidance.. Failure to comply with the post-procedural checking guidelines.. Double lumen catheter insertion was not a frequently performed procedure in the ward where some involved team members were not familiar with the procedure.. Enforce strict compliance with the Bedside Procedure Safety Checklist.. Update the existing department procedural document on catheter insertion, highlighting on post procedural guide wire checking. 3. Consider adding a critical checking step to ensure removal of guide wire before ending the procedure (e.g. handing of guide wire to nurses before issuing the suture needle).. Enhance staff training on Central Venous Catheter insertion.

3 One piece of gauze roll was found retained in the patient s wound cavity A patient was admitted for RIGHT thigh abscess and RIGHT knee septic arthritis. Emergency arthrotomy and incision and drainage (I&D) of RIGHT thigh abscess was performed. Packing of gauze rolls was documented in the Wound Assessment Record and in the operation record. A visible tail of each long gauze roll was placed over the wound surface instead of peri-wound surrounding skin. A third gauze roll (same type and size as the packing gauze) was used as the cover dressing of the wound. One day after the operation, wound dressing was performed. The cover dressing (gauze roll) was removed from the wound cavity. It was perceived as one of the originally packed gauze roll. Another gauze roll was removed. It was perceived that gauze rolls had been removed. A new long gauze roll was packed and was documented as gauze roll packed. Daily wound dressing was performed on post-operative day to 5. One gauze roll was removed with one new gauze roll packed each time. On day 6 after operation, wound debridement was performed and a retained gauze roll was found inside the wound.. Used same type of dressing material (long gauze roll) for both wound packing and cover dressing.. Adopted the practice of leaving a visible tail of packed gauze roll over the wound instead of peri-wound surrounding skin by the involved surgeons.. Use different materials for wound packing and cover dressing.. Reinforce and align the practice of leaving a visible tail of packed gauze roll over the peri-wound surrounding skin. A 0.9 x 0.mm foreign body found at the medial side of the patient's RIGHT patella A patient was admitted for RIGHT patella fracture. Open reduction and internal fixation (ORIF) of the RIGHT patella was done. 8G stainless steel wire was used for fixation. During the operation, readjustment and cutting of the wire was required. Difficulties were encountered on cutting the wire. Intraoperative X-ray upon completion of the procedure did not show any evidence of foreign body. Subsequent post-operative X-ray showed a 0.9x0.mm foreign body over the medial side of the RIGHT patella. Open disclosure was performed. It was decided not to remove the foreign body. It was concluded by the Panel that: Since the procedure and instruments used in the operation were appropriate, no specific recommendations could be made. 3

4 Sentinel Events Wrong patient / part Haemodialysis (HD) catheter inserted into wrong patient Patient A with history of renal impairment, was admitted to Intensive Care Unit (ICU) for respiratory failure. had received continuous renal replacement therapy (CRRT) for deteriorating renal function previously. had no immediate need for renal dialysis for the time being. Patient B was admitted for haemoptysis. developed acute on chronic renal impairment, requiring CRRT in ICU. was indicated for haemodialysis (HD) catheter insertion. Due to miscommunication, patient A instead of patient B was brought into the renal minor operating theatre (OT) for HD catheter insertion. In the renal minor OT, an electronic Informed Consent Form under patient B s profile was generated from the clinical management system (CMS). Patient A instead of patient B was asked to sign on the consent form. HD catheter was inserted at the RIGHT internal jugular vein of patient A. When checking post-procedural documents, the error was noted. The catheter in patient A was not removed in view of impaired and deteriorating renal conditions. An HD catheter was inserted for patient B for haemodialysis.. No structured booking system for interventional procedures in renal minor OT.. Inadequate concept about procedural safety among the team. 3. Unsatisfactory process in obtaining consent.. Establish a structured booking system in renal minor OT.. Boost up the procedural safety concepts among the team. 3. Ensure correct patient identification in obtaining consent and in the procedure.

5 Inpatient Suicide Patient absconded from the hospital and found dead outside the hospital A patient with known psychiatric diagnosis of delusional disorder was admitted to psychiatric ward for increased paranoid ideas. The patient was noted to have significant improvements after one week of management and was allowed to attend the training in Psychiatric Occupational Therapy (OT) Department. Two weeks later, during the occupational therapy session, the patient suddenly dashed out of the toilet and ran towards the main entrance of the OT Department. The accompanying supporting staff shouted for help. The patient broke the digital door lock and ran out of the hospital. Local hospital-wide search was performed. Police was contacted. Later in the afternoon, the patient was found hanging on a scaffolding of a residential building near the hospital. The patient was certified dead at the Accident and Emergency Department.. Unanticipated change in mental state of patient might have led to sudden abscondence impulse.. The unlocked door at the Psychiatric Occupational Therapy Department was not able to prevent the patient from absconding. Recommendation Install access control at Psychiatric OT department entrance doors for tighter control of ward / clinical areas exits while taking into account of fire safety in order to prevent patients from absconding. Serious Untoward Events Of the 9 SUE cases reported in Q 07, 7 were due to medication errors and were due to patient misidentification. The medication error cases involved giving known drug allergen (KDA) to patients (9), Dangerous Drugs (5), Anticoagulant (), Electrolytes (), Insulin (), Vasopressors & Inotropes () and others (7). Of the 9 known drug allergen cases, 3 developed mild symptoms which subsided after treatment. The others had no allergic reaction. Number of KDA cases in the last four quarters Known Allergy Allergen prescribed Penicillin Cefazolin Ibuprofen Ketorolac Paracetamol or Dologesic Paracetamol () Quinolone Levofloxacin 6 Largactil Phenergan Gelofusine Gelofusine Holopon Buscopan % Lignocaine % Lignocaine 0 Others 8 5 Related to NSAID 0 3 Q 07 Paracetamol Related to Penicillin Q 07 Q3 07 Q 07 5

6 Serious Untoward Events Medication Error Known Drug Allergy - Not aware that Dologesic contains Paracetamol A patient had history of multiple drug allergies, including allergy to Dologesic. The patient complained of headache and was prescribed Paracetamol. Both the doctor and the nurse who administered the drug were not aware that Dologesic contains Paracetamol. The medication incident was noted by the Pharmacy staff who informed ward staff. The patient had developed mild symptoms with erythematous rash afterwards. The rash had resolved after treatment. Check and clarify unfamiliar medications before prescription and administration Reinforce the practice to check patient s allergy status by referring to the CMS or printout Dologesic = Dextropropoxyphene HCl + Paracetamol Vancomycin was administered at a wrong infusion rate A patient with Spinal Muscular Atrophy with Respiratory Distress (SMARD) was prescribed Vancomycin. He has history of Redman Syndrome upon administration of Vancomycin which subsided with Piriton treatment. One morning, the doctor verbally ordered Vancomycin 00mg over hours after giving a stat dose of Piriton. The nurses prepared Vancomycin after confirming the verbal order with the doctor including checking of the drug name, dose, route and frequency by nurses. The prepared Vancomycin was brought to the patient s bedside without the Medication Administration Record (MAR) sheet. Vancomycin was infused at a rate of 00ml/hr. The patient did not develop Redman syndrome.. Failure to comply with Basic Nursing Standards for Patient Care Medication Administration Intravenous Infusion.. Skipped the step of independent checking of infusion rate during administration.. Write the infusion rate on IV drug label to reinforce the process of checking infusion rate.. Reinforce staff education on the importance of following nursing standards by checking infusion rate against MAR, and provide refresher training on IV infusion especially with the use of infusion pump. Infuse over at least 60mins or at rate no more than 0mg/min, whichever is longer 6

7 Medication Error Known Drug Allergy Lignocaine was prescribed and administered to a patient with known allergy A patient with history of allergic reactions to local anaesthetics was planned to undergo skin biopsy. Doctor A prescribed Fentanyl Citrate subcutaneous injection (for pain control) and Piriton intravenous injection to the patient. The injections were administered by Nurse B before the procedure. Prior to the skin biopsy, Doctor C prescribed and administered 0.5ml % Lignocaine to the patient. After the procedure, Doctor C and Nurse D filled in the Bedside Procedure Checklist and marked the patient having a known drug allergy / alert. The patient did not have any adverse reaction. Strengthen the checking process for bedside procedures Overdose of Morphine infusion in an 8 days old baby boy A newborn baby with Transposition of Great Arteries underwent cardiac operation on Day 8 of life, and was transferred to the Intensive Care Unit (ICU) for post-operative care. The ICU nurse printed the Resuscitation Medication Reference Chart (reference chart) from the local computer, but selected the wrong reference chart for patients >0kg, despite the baby s body weight of only 3.8kg. The doctor prescribed morphine 0mg in 50ml D5 (with reference to the >0kg reference chart). Upon review by another doctor, the baby was noted to be in deep sleep. On reviewing the MAR, it was noted that the Morphine dosage was equivalent to mcg/kg/hr, exceeding the reference range of 0-0mcg/kg/hr for a -5kg baby. Antidote was given. Morphine and sedation infusion was stopped. The baby was discharged on Day 3.. Staff was not familiar with the dosage of Morphine.. Staff was not aware of different sheets of Resuscitation Medication Reference Chart for paediatric patients with different body weights. 3. Warning signs were not explicitly displayed in the computer screen to alert staff for selecting the wrong templates.. Remind and ensure all staff to cross check all elements including dosage and drip rate when using this Resuscitation Medication Reference Chart.. Strengthen mechanism to safe guard the use of Resuscitation Medication Reference Chart. Re-design the Reference Chart in order to prevent the use of wrong templates (of wrong body weights). 3. Strengthen education and orientation programmes on the use of this Reference Chart. 7

8 Local Sharing Procedure Safety Policies To reinforce surgical, interventional and bedside procedure safety in the Hospital Authority, the Surgical / interventional / bedside procedure safety policies were revised in Jan 08. The updated policies will take effect from July 08. SIGN IN The updated policies had emphasised on the importance of: SIGN IN The timing of SIGN IN and TIME OUT ; The need for checking relevant radiological images in the TIME OUT process; and TIME OUT TIME OUT The counting and checking of the completeness of instruments. Near miss case (rectified during SIGN IN ) Patient was planned for RIGHT cementless hemiarthroplasty. During the SIGN IN procedure, LEFT hip fracture was indicated in the consent form. The fracture side was verified by the patient and the surgeon, with the confirmation of X-ray imaging. The correction was made before undergoing regional anaesthesia. The booking in the Operating Theatre Management System (OTMS) was amended. Near miss case (rectified during TIME OUT ) A patient was planned for removal of implant for fracture RIGHT tibia and fibula. During the TIME OUT procedure, it was noted that the wrong operation side was indicated in the consent, patient notes, admission slip. The correct side was the LEFT side while site marking was correct. The operation side was verified with the patient s old medical notes, previous operation record and X-ray images. The consent and OTMS were amended after confirmation. EDITORIAL BOARD Editor-in-Chief: Dr N C SIN, CM(PS&RM), HAHO Board Members: Dr C W LAU, SD(Q&S), HKEC; Dr Osburga P K CHAN, SD(Q&S), KCC; Dr Petty LEE, P(CPO), HAHO; Dr Flora TSANG, SM(PS&RM), HAHO; Dr Gary NG, M(PS&RM), HAHO; Ms Katherine PANG, M(PS&RM), HAHO Advisor: Dr Lawrence LAI, HOQ&S Honorary Senior Advisor Suggestions or feedback are most welcome. Please us through HA intranet at address: HO Patient Safety & Risk Management