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:

1

5

1012345

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)

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.

1

5 3 53

5 7

2

3

1

211

0

2

4

6

8

10

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)

2 3

21

11 12

18

5

02

7

0

5

10

15

20

25

Q1 2015 Q2 2015 Q3 2015 Q4 2015

Medication errorPatient misidentification

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

2 3

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.

4 5

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.

4 5

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.

3 2 2 3

21 1

2

1 1

1

2 1

Q1 2015 Q2 2015 Q3 2015 Q4 2015

OthersParacetamolNSAIDPenicillin

Distribution of drugs related to KDA KDA cases in Q4 2015

4 5

Known allergy Allergen prescribed

UnasynAugmentin (2 cases)

Ampicillin

Paracetamol Paracetamol

Streptomycin Flu vaccine

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

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

6 7

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.