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ISSUE 41 APR 2016A Risk Management Newsletter for Hospital
Authority Healthcare Professionals
RISK ALERT
Risk Mitigation Strategy - Guide Wire Retention
Five incidents of retained guide wire after insertion of central
venous catheter (CVC) were reported in 2014/15. All involved the
use of triple lumen CVC. Retention of guide wire may pose serious
harm to patient and require invasive procedures for retrieval. Here
are some measures you can apply to mitigate the risk of retained
CVC guide wire:
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11/12 12/13 13/14 14/15 4Q15
CONTROL the guide wire end and ensure it is always VISIBLE while
advancing the catheter.
CONFIRM removal of the guide wire before connecting to infusion
line.
COUNT the used guide wire before ending the procedure.
in this issueRisk Mitigation Strategy - Guide Wire
RetentionSentinel Events (SEs) (Q4 2015)
Retained instruments / material Inpatient suicideMaternal death
/ serious morbidity Others
Serious Untoward Events (SUEs) (Q4 2015)
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SENTINEL EVENTS
Retained Instruments / Material
Guide wire Doctor decided to insert a CVC for inotrope
infusion.Bedside Procedure Safety Checklist was not used.Nurse did
not attend the whole procedure but only returned after doctor had
completed the procedure.Chest X-ray confirmed a retained guide
wire.Retrieval of guide wire in cardiac center was
required.Patient’s clinical condition remained stable.
Contributing factors:1. No critical checking steps to ensure
removal of guide wire.2. Inadequate training on CVC insertion.3.
The design of Bedside Procedure Safety Checklist cannot fit into
the CVC insertion workflow.Recommendations:1. Incorporate a
critical checking step in verifying guide wire removal before
ending the procedure.2. Strengthen training on CVC insertion.3.
Revise the design of Bedside Procedure Safety Checklist.
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5 7
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211
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12
Wrong patient / partRetained instruments / materialInpatient
suicide
Maternal morbidityOthers
Distribution of SUE in the last four quartersDistribution of SE
in the last four quarters
Q1 2015 Q2 2015 Q3 2015 Q4 2015
Calligraphy by Dr Ngai Chuen SIN
"When nothing is everything“
To say that “nothing happened” does not usually sound like great
news or something to give thanks for. However, for healthcare
workers who are constantly working in a busy and complex clinical
setting, “nothing untoward happened” could be considered fortunate
or good outcome. In striving towards “nothing untoward happened”,
we must always remember that learning and sharing from others’
medical incidents and creating a safety culture are of utmost
importance. Dr Ngai Chuen SIN
Chief Manager (Patient Safety & Risk Management)
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18
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10
15
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25
Q1 2015 Q2 2015 Q3 2015 Q4 2015
Medication errorPatient misidentification
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Broken tip of silicone tube metal introducerA patient underwent
endoscopic surgery for management of nasolacrimal duct
obstruction.Surgeon failed to intubate the lacrimal canaliculi of
left eye by using a single-use silicone tube. The procedure was
successfully reattempted after using a more rigid metal introducer
inside the Catalano intubation set.During reprocessing, the end of
metal introducer was found broken.X-ray confirmed a 4mm metallic
foreign body retained in the region of superior canaliculi.
Contributing factors:1. Unfamiliar with the instrument.2.
Failure to check the completeness of instrument. Recommendations:1.
Suspend the use of Catalano intubation set. 2. Enhance staff
awareness on checking the completeness of used instruments.
A piece of bone cementA patient underwent left unipolar hip
arthroplasty for fractured neck of femur.Surgeons packed the
acetabulum with gauze to prevent cement leakage.Inspection and
palpation of the acetabulum were performed prior to reduction.After
reduction, the passive range of movement was also satisfactory.Post
operative X-ray 2 days later showed a foreign body inside the
acetabulum. Subsequent computed tomography scan revealed suspected
retention of a small piece of cement.Clinical team decided not to
remove the cement.
Contributing factor:Low alertness of staff on potential risk of
retained cement.
Recommendations:1. Perform intraoperative imaging if there are
doubts of loosened bone cement.2. Enhance staff alertness on
potential risk of retained cement in similar orthopaedic
procedures.
Q4 2015
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SENTINEL EVENTS
Inpatient Suicide
HangingA patient was admitted for suspected recurrence of
stomach cancer. 8 days after admission, patient committed suicide
in ward by hanging with a torn bed sheet over bedside curtain
rail.
Contributing factor:Presence of high risk facilities in
premises.
Recommendation:Consider ceiling mount curtain rails where
applicable, e.g. single rooms, isolation rooms and side rooms.
When designing for new wards or at major renovation /
refurbishment of existing wards, please make reference to:
- Guidelines on Hospital Security Design Planning
(CCHS-G-002-V3) Annex 5(d)
SuffocationA patient was admitted to a psychiatric hospital for
management of recurrent depression.Patient was assessed as having
suicidal risk and was put on suicidal observation.In early morning
of the next day, patient was found committed suicide by
suffocation.
Home leaveA patient with metastatic stomach cancer was admitted
for symptoms control.Suicidal risk was assessed as low on
admission.2 weeks later, home leave was granted for patient to
settle personal matters.The patient jumped from height on the same
evening.
Patient suicide during Home Leave is a SE.
Contributing factor:The current observation mode for patient
with high suicidal risk was not adequate and specific.
Recommendation:Standardize practice and enhance training on
intensive observation for patients with suicidal risk.
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SENTINEL EVENTS
Inpatient Suicide
HangingA patient was admitted for suspected recurrence of
stomach cancer. 8 days after admission, patient committed suicide
in ward by hanging with a torn bed sheet over bedside curtain
rail.
Contributing factor:Presence of high risk facilities in
premises.
Recommendation:Consider ceiling mount curtain rails where
applicable, e.g. single rooms, isolation rooms and side rooms.
When designing for new wards or at major renovation /
refurbishment of existing wards, please make reference to:
- Guidelines on Hospital Security Design Planning
(CCHS-G-002-V3) Annex 5(d)
SuffocationA patient was admitted to a psychiatric hospital for
management of recurrent depression.Patient was assessed as having
suicidal risk and was put on suicidal observation.In early morning
of the next day, patient was found committed suicide by
suffocation.
Home leaveA patient with metastatic stomach cancer was admitted
for symptoms control.Suicidal risk was assessed as low on
admission.2 weeks later, home leave was granted for patient to
settle personal matters.The patient jumped from height on the same
evening.
Patient suicide during Home Leave is a SE.
Contributing factor:The current observation mode for patient
with high suicidal risk was not adequate and specific.
Recommendation:Standardize practice and enhance training on
intensive observation for patients with suicidal risk.
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SERIOUS UNTOWARD EVENTS
Q4 2015
Maternal Death / Serious Morbidity
In Q4 2015, two cases were reported:- Severe postpartum
haemorrhage secondary to uterine atony- Severe endometritis
secondary to septic abortion
Others
A ventilator was switched to standby mode for 1 minuteA patient
was transferred to Intensive Care Unit (ICU) for management of
severe sepsis. Patient required ventilator support, high dose
inotropes and renal replacement therapy.To adjust the connection of
the ventilator, a nurse switched the ventilator to standby mode,
but did not switch it back to normal operating mode
afterwards.After approximately one minute, the patient developed
cardiac arrest. Patient regained circulation after resuscitation
and had a brief period of improved consciousness.Subsequently,
patient deteriorated again and passed away later on the same
day.
Contributing factors:1. Non-compliance with guidelines when
adjusting connection in ventilator.2. Absence of audio alarm
warning signal for standby mode to alert staff.Recommendations:1.
Reinforce the training of ICU nurses in adjusting connection in
ventilator.2. Enhance “Guideline on Management of Patient on
Intermittent Positive Pressure Ventilation”.3. Conduct regular
audit on staff’s compliance with the guideline.
Of the 25 SUE cases reported in Q4 2015, 18 were medication
error and 7 were patient misidentification. The medication error
involved giving known drug allergens (KDA) to patients (5), use of
anticoagulants (2), dangerous drugs (3), electrolyte (1),
chemotherapeutic agent (1) and others (6).
Of the 5 KDA, 2 developed mild symptoms which subsided after
treatment. The others had no allergic reaction.
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Q1 2015 Q2 2015 Q3 2015 Q4 2015
OthersParacetamolNSAIDPenicillin
Distribution of drugs related to KDA KDA cases in Q4 2015
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Known allergy Allergen prescribed
UnasynAugmentin (2 cases)
Ampicillin
Paracetamol Paracetamol
Streptomycin Flu vaccine
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SERIOUS UNTOWARD EVENTS
Medication Error
Vancomycin given as intravenous (IV) bolusVancomycin was
administered as bolus to a patient.Patient developed mild red man
syndrome which subsided spontaneously.
Known durg allergy
A female patient had known allergy to Unasyn was admitted.
In CMSᶿ, allergy history was entered as FREE TEXT, instead of
STRUCTURED ALERT.
Intravenous ampicillin was prescribed in IPMOE*.Both the doctor
and nurse were not aware Unasyn contains ampicillin.
Pharmacy staff did not notice the allergy history.
IV ampicillin# was administered to patient.
Patient developed urticaria which subsided after medical
treatment.
CMS
Free Text Allergyallergy to Unasyn
The system cannot perform cross checking on
Free Text Allergy!
Unasyn(Ampicillin and
Sulbactum)is in Penicillin Group.
Vancomycin must be diluted (at least 500mg/100mL) and
administered by slow IV infusion (no more than 10mg/minute).
*IPMOE=Inpatient Medication Order Entry
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#Ward stock item
ᶿCMS=Clinical Management System
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SERIOUS UNTOWARD EVENTS
Medication Error
Vancomycin given as intravenous (IV) bolusVancomycin was
administered as bolus to a patient.Patient developed mild red man
syndrome which subsided spontaneously.
Known durg allergy
A female patient had known allergy to Unasyn was admitted.
In CMSᶿ, allergy history was entered as FREE TEXT, instead of
STRUCTURED ALERT.
Intravenous ampicillin was prescribed in IPMOE*.Both the doctor
and nurse were not aware Unasyn contains ampicillin.
Pharmacy staff did not notice the allergy history.
IV ampicillin# was administered to patient.
Patient developed urticaria which subsided after medical
treatment.
CMS
Free Text Allergyallergy to Unasyn
The system cannot perform cross checking on
Free Text Allergy!
Unasyn(Ampicillin and
Sulbactum)is in Penicillin Group.
Vancomycin must be diluted (at least 500mg/100mL) and
administered by slow IV infusion (no more than 10mg/minute).
*IPMOE=Inpatient Medication Order Entry
6 7
#Ward stock item
ᶿCMS=Clinical Management System
Over-infusion of heparin during haemodialysis (HD)A nurse
prepared a syringe filled with 9ml unfractionated heparin (1000
units/mL) for HD.The syringe was improperly fitted into the heparin
pump of the dialysis machine.An action alert message was displayed
but was bypassed.The heparin syringe was found empty shortly after
the start of HD.Blood test showed prolonged Activated Partial
Thromboplastin Time (APTT) which was normalised spontaneously; and
patient had no clinical bleeding.
Q4 2015
Contributing factors:1. Non-compliance with the dialysis
guidelines.2. Unfamiliar with handling of heparin
pump.Recommendations:1. Enhance training and supervision of renal
nurses.2. Put a reminder near the HD machine to alert staff on the
correct way of handling heparin pump.3. Alert staff on this
potential risk.
Installation of syringe to the heparin pump
The syringe wings should be positioned between the barrel
holders and the bracket. If the syringe is not properly connected,
the rate of heparin infusion will be affected by the blood pump
rate (~100-300mL/minute during operation) instead of being
controlled by heparin pump (~1-2mL/hour).
barrelholders bracket
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SERIOUS UNTOWARD EVENTS
Unnecessary change of morphine infusion pump rate resulting in
overdose
A patient with metastatic melanoma was admitted for suspected
perforated bowel.Two infusion lines of intravenous fluid and
morphine infusion (30mg morphine in 100mL 5% dextrose) at
3.3mL/hour were set up on a drip pole at patient’s bed.While the
bag for intravenous fluid was almost empty, a nurse brought a new
bag and instructed a pupil nurse to make a replacement.After
changing the bag, the pupil nurse inadvertently adjusted the
morphine infusion pump rate from 3.3mL/hour to 83.3mL/hour, as she
assumed the morphine infusion pump was for the intravenous
fluid.
EDITORIAL BOARDEditor-in-Chief: Dr N C SIN, CM(PS&RM),
HAHO
Board Members: Dr K Y PANG, Dep SD(Q&S), HKEC; Dr Osburga P
K CHAN, SD(Q&S), KCC; Dr Petty LEE, P(CPO), HAHO;Mr Fred CHAN,
SM(PS&RM), HAHO; Dr Venus SIU, SM(PS&RM), HAHO; Dr C M LAM,
M(PS&RM), HAHO;
Ms Katherine PANG, M(PS&RM), HAHOAdvisor: Dr Lawrence LAI,
HOQ&S Honorary Senior Advisor
Suggestions or feedback are most welcome. Please email us
through HA intranet at address: HO Patient Safety & Risk
Management
Contributing factors:1. Problem of confirmation bias of nurse
learner in identifying the correct infusion line.2. Gap in the
clinical supervision relating to competency assessment of the nurse
learners.
Recommendations:1. Review the setting up of the intravenous
infusion system with inclusion of human factors to facilitate safe
practice.2. Review clinical supervision system and strengthen the
competency assessment of the nurse learner.
http://nursenet.home/Coordinating%20Committee%20%20Grade%20Nursing%20Approved%20Pap/Nursing%20Quality%20and%20Safety/Nursing%20Standard/Basic%20Nursing%20Standards%20on%20Medication%20Administration%20-%20Intravenous%20Infusion.pdf
IV fluidinfusion
Morphineinfusion
at3.3mL/hour
Learning point:
ALWAYS TRACE all infusion / device lines back to their origins
before connecting or disconnecting any devices or infusions.