risk alert - ha.org.hk
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RISK ALERTISSUE 63 OCT 2021
A Risk Management Newsletter for Hospital Authority Healthcare Professionals
IN THIS ISSUE
Sentinel Events (SEs) (2Q 2021)
Wrong Patient / Part
Retained Instruments / Material
Inpatient SuicideSerious Untoward Events (SUEs) (2Q 2021)
Local Sharing
* NSAID Related Cross-Sensitivity
* Incidents Related to Medications Discontinuation
* Discontinuation Function in MOE
Patient Safety – Beyond Safety
Dr LAW Chun-bon, AlexanderCluster Chief ExecutiveKowloon West Cluster
Modern treatment is very effective but at the sametime, risky. With extra-ordinary therapeutic capability,our healthcare teams are increasingly engaged in theuse of sophisticated medical therapeutics andinterventions for patients with unstable conditions. Inaddition, modern treatments require coordinated workfrom many professionals from different disciplines andspecialties. There is no room for error.
Let’s capture this opportunity.
To reduce the probability of error, our usual solution is to add layers of checking anddefenses. While this may prevent error in a specific task, this adds complexity to theoperation and may impact on another corporate imperative – efficiency. Is it possibleto address risk without sacrificing efficiency? Safety and quality is two sides of a coin.Focusing on efficiency and quality may be another way to tackle safety. One way toimprove efficiency and quality is workflow re-engineering. By deriving a more efficientand effective way to deliver service, most often harnessing the power of moderninformation technologies, we may be able to “kill two birds with one stone”.Digitalizing workflow with or without workflow re-engineering is two completelydifferent games. In my opinion, although more complicated, all attempts to digitalizeworkflow should combine with workflow re-engineering in order to fully capture theadvantage of digitalization. The Smart Hospital policy of HA is a golden opportunityfor us to improve patient safety with the added dimension of improving efficiency.
Let’s capture this opportunity.
1
Distribution of SUE in the last four quartersDistribution of SE in the last four quarters
Wrong Patient / PartLeft femoral component of total knee replacement (TKR) implant placed in right knee
Patient underwent robotic-assistedbilateral TKR. Details of implantcomponents for LEFT and RIGHTknees were written on the whiteboard in operating theater.
After LEFT TKR, difficulty wasencountered during RIGHT TKR.Surgeon decided to change theprosthesis system from CruciateRetaining (CR) to Posterior Stabilizing(PS). Therefore, a new set ofinstruments and implants had to bearranged.
LEFT femoral component was pickedand given to circulating nurse.
Nurse counter-checked with surgeonby reading out the package labelinformation.
After procedure, post-operative X-rayrevealed a LEFT femoral componentin patient’s RIGHT knee. RevisionRIGHT TKR was done afterwards.
Why did it happen?
o The Team did not checkthe implant informationand laterality againstwhite board
o The change of surgicalplan from CR to PSprosthesis system andthe operation involvingbilateral kneescontributed to the risk ofpicking wrong prosthesis
o The printing on implantpackage was too smallto be read clearly
How to prevent?
2. Introduce “Stop Moment” for implant verification3. Enhance the clarity of whiteboard display by displaying
one-sided implant information on the board at a time
1 2 11
4 33
1
2
22
2
1
3
0
5
10
15
Q3 2020 Q4 2020 Q1 2021 Q2 2021
Others Wrong infant/ abductionABO incompatibility Gas embolismMaternal morbidity Inpatient suicideMedication error Retained instruments/materialWrong patient/part
12
27
19
15
24
2 30
5
10
15
20
25
30
Q3 2020 Q4 2020 Q1 2021 Q2 2021
Medication error
Patient misidentification
1. Read out packageinformation by circulatingnurse and whiteboardinformation by surgeonsimultaneously duringimplant verificationprocess
2
Retained Instruments / Material
Why did it happen?o Arterial wall spasm is common in children and
may cause gripping on such device. o Advancement of the device may result in
arterial telescoping, causing vascular insufficiency.
Use of Device Integrity of device foot should be checked after removal from the body. Careful patient selection for device use, especially in children. Consider angiography or other appropriate imaging immediately before device application to
accurately assess vessel size for children and if indicated.
Learning Points
Root CauseChecking the device foot following arteriotomy closure was not a routine
Broken foot of a Vessel Closure Device (Device)
During a paediatric splenic artery embolization,after the vascular sheath was removed from theright femoral artery, a vessel closure device(“device”) was deployed in view of patient’sbleeding risk. The first device failed to achieve asecure knot and a second device was used.Following ultrasound and close monitoring, patientwas stable and discharged on post-operative Day 4.
During follow-up, patient was noted to have rightlower limb claudication with weak pulses. UrgentCT angiogram, followed by emergency right groinexploration revealed right common femoral arterystenosis and a broken foot from the device. Patienthad an uneventful post-operative recovery afterarterial bypass surgery.
Broken foot of Device
3
Retained Instruments / Material
Broken catheter in patient’s duodenum
Broken catheter placed next to suction catheter in use in the hospitals
Check suction catheter’s integrity before andafter use
Enhance staff awareness in assessing patients’fitness for oro-pharyngeal (OP) suction
Agitated or struggling patients may haveincreased risk of biting the catheter during OPsuction
Learning Points
Gauze in sacral wound
A non-communicable old-aged homeresident had frequent admissions in the pastfew months. He was on nasogastric tubefeeding, and had episodes of agitation withstruggling.
During a recent admission, esophago-gastro-duodenoscopy (OGD) was performed toinvestigate the cause of anemia. A 5cm long“broken catheter” was discovered in theduoduenum.
After investigation, the "broken catheter"was likely the distal end of suction catheterused in hospital. However, how and when itwas retained could not be identified.
Ensure the number of dressing removed same as previously packed in record
How to Prevent?
1. Ensure standardized wound assessment anddocumentation to facilitate communication andenhance handover safety
2. Leave visible tail (at least 3cm) of packingmaterials outside the wound with properanchorage to facilitate detection and retrieval
3. Check the removed packing quantity against theprevious record
4. Consult wound specialist for complicated wound
Acknowledgment: KEC Q&S Office
o A patient with sacralwound was hospitalized.During wound nurseassessment, a retainedgauze was found in thewound.
4
Inpatient Suicide
Of the 18 SUE cases reported in 2Q 2021, 15 cases were related to medication errors, involving knowndrug allergy (KDA) (2), anticoagulant (3), antiplatelet (1), insulin (3), chemotherapeutic agent (1), oralhypoglycemic agent (1), neuromuscular blocking agents (1) and others (3).
Number of KDA cases in the last four quarters
Known Allergy Allergen prescribed
Aspirin Ketorolac (Toradol)
Ketoprofen Aspirin
Patient in isolation room was found incardiac arrest by nurse. During cardio-pulmonary resuscitation (CPR), pieces oftissue papers in ball shape were retrievedfrom the patient’s throat. Despite activetreatment, the patient succumbedafterwards. The case was reported to thePolice and Coroner.
by Suffocation
1 2 A metastatic lung cancer patient was admitted toan oncology ward for dyspnoea. On a weekend,doctor broke the bad news to patient that he wasnot suitable for targeted therapy. The patientappeared to have good acceptance to theprognosis and opted for supportive care and Do-Not-Attempt Cardiopulmonary Resuscitation(DNACPR).
In the next morning, the patient was found, withhis head covered by quilt and wrapped by plasticbag. Despite resuscitation, the patientsuccumbed. The case was reported to the Policeand Coroner.
Psychosocial support, e.g. by chaplain andsocial worker, and more frequentcompassionate visit in compliance withprevailing infection control policy mayhelp alleviate patients’ stress and facilitateventilation of feeling, especially whomwith declining health condition.
Both patients’ mood was all along stable, without any sign ofdepression / suicidal tendency
Suicidal risk assessment and monitoring were appropriate
Findings
12
5 22
1
11
1
0
2
4
6
8
10
Q3 2020 Q4 2020 Q1 2021 Q2 2021
Others
Quinolone
Paracetamol
Related to NSAID
Related to Penicillin
sClinical documentation regarding details ofbreaking bad news, followed by additionalverbal communication to nurses by doctor is agood practice.
5
Extracted from Cavkaytar et al (2019). Characteristic of NSAID-induced hypersensitivity reactions in childhood. Pediatric Allergy and Immunology. 30, 25–35.
Aspirin
IbuprofenKetorolac
DiclofenacNaproxen
KetoprofenIndomethacin
Etoricoxib
Celecoxib
Medication Error
Known drug allergy
A patient with acute myocardial infarctionwas given Aspirin in ambulance. Upon arrivalat AED, the patient verbally confirmed that hehad no drug allergy.
Extra Aspirin and Ticagrelor were prescribedbefore percutaneous coronary intervention(PCI). Shortly afterwards, the doctor noticed
the patient’s allergy historyto Ketoprofen in the CMS alert.
Upon further enquiry, patientexplained that he was allergic
to some kind of injectable medication but notoral drug. Patient was prescribed withsteroid cover and did not develop allergicreaction.
1 2
Check for cross-allergy
Seek advice from senior colleague / pharmacist if in doubt
Check for CMS allergy alert before prescription and administration
During a consultation in Accident andEmergency Department (AED), a doctordocumented "Aspirin and Acetylsalicylicacid” allergy on patient’s AED attendancerecord and Clinical Management System(CMS). Doctor initially prescribed Tramadolinjectionfor the patient.
Due to persistentpain, Ketorolacinjection was laterprescribed and administered.
The doctor and nurse could not correlatethe cross-sensitivity of Ketorolac andAspirin, during prescription andadministration process.
6
Discontinuation Function in Medication Order Entry (MOE)
Please mark Medication Discontinuation to avoid
repeating discontinued drug!
To facilitate doctor to mark discontinuation explicitly andto avoid unintentional repetition of drug, medicationdiscontinuation function is available in Medication OrderEntry (MOE).
Discontinued drug history canbe reviewed through MOE, ePRand Discontinued Drug HistoryEnquiry in CMS menu bar.
EDITORIAL BOARDEditor-in-Chief: Dr Sara HO, CM(PS&RM), HAHO
Board Members: Dr Ian CHAN, Dep SD(Q&S), KEC; Dr W M CHEUNG, SD(Q&S), KWC; Mr Brian CHING, P(CPO), HAHO; Dr Jackie CHEUNG, SM(PS&RM), HAHO; Mr M N CHAN, M(PS&RM), HAHO;
Mr Charles CHEUNG, M(PS&RM), HAHO.Suggestion or feedback is most welcome. Please email us through HA intranet at address: HO Patient Safety & Risk Management
Medication Discontinuation Function in MOE
Discontinued item will be strikethrough with reason displayed, e.g. allergy or drug regimen adjusted. Item is not allowed to repeat in MOE History.
Please provide a reason for discontinuation
Right click on the drug to perform discontinuation