ISSUE 40 JAN 2016A Risk Management Newsletter for Hospital Authority Healthcare Professionals

RISK ALERT

Improving patient safety is a challenging task as clinical incidents do happen in any modern healthcare setting. The lessons learnt from the incidents can be used to support new system(s) or redesign of services to improve quality and safety for safer, better care.

Looking back, 2015 was a ‘rewarding’ year for the Hospital Authority (HA), with improvement in the overall Sentinel Event/Serious Untoward Event (SE/SUE) figures and the publication of the long-awaited ‘Clinical Incident Management Manual’. There was no SE related to medication error, while the number of SUE related to medication error dropped to a record low.

Learning from the medication incidents, such as the unnecessary prolonged use of steroid and omitted double anti-platelet therapy in a post percutaneous coronary intervention patient, in 2013/14, HA took actions to educate staff, focusing on the occurrence and prevention of medication error. This involved system changes with IT enhancement and the implementation of the In-patient Medication Order Entry (IPMOE) to minimize transcription errors and facilitate timely review of orders. Drug allergy checking was also simplified.

As we know, sustainable corrective action aiming to control or eliminate risk, is the key but most difficult part of the patient safety formula, as healthcare is increasingly complex with inherent risk.

I would like to draw your attention to the 5 cases of retained guide wire of central venous catheter in 2014/15. Most of them were inserted in emergency clinical situations and distractions by colleagues was a possible contributing factor. In response to these incidents, many hospitals developed checklists to prompt the operator to inspect the guide wire after removal. This measure is certainly useful but may not be a risk-proof solution. It is because maintaining stringent control of the guide wire continuously throughout the procedure is still difficult to mitigate the risk due to human error. We urge the clinical experts and relevant stakeholders to explore alternative features in the design of the central line kits.

HARA is one of the quality improvement tools/platforms for sharing expertise, ideas, knowledge, and solutions. This simple format aims to highlight the essential messages and making it an enjoyable read. After all, our common goal is to improve patient safety.

By the time this issue is published, I will be serving in a new post. I believe my successor would keep on and move ahead with our worthy work.

Wishing you a happy & healthy 2016!

Dr Rebecca LAMChief Manager (Patient Safety & Risk Management)

IN THIS ISSUE Sentinel Events (SEs) (Q3 2015) Retained instruments / material Inpatient suicide Others Serious Untoward Events (SUEs) (Q3 2015) Local Sharing Surgical �re

Distribution of SEs in the last four quarters

29

21

21

21

13

0

10

20

30

Q4 2014 Q1 2015 Q2 2015 Q3 2015

Distribution of SUEs in the last four quartersMedication errorPatient misidentification

Consequence of SEs in Q3 2015

5, Minor3, Permanentloss of functionor death

6

5

5

4 5

12

Other adverse events resulting inpermanent loss of function or death

(excluding complications)

Maternal death or serious morbidityassociated with labour or delivery

Death of an inpatient from suicide(including home leave)

Retained instruments orother material after

surgery / interventional procedure

Surgery / interventionalprocedure involving the

wrong patient or body part

1

1

1

6

2

2

5

5 3

2

6

1

5

5

1

1

3

7

5

2

1

0 5 10 15 20

Q4 2014Q1 2015Q2 2015Q3 2015

11

02

Sentinel Events

Retained Instruments / MaterialRetained drain after total knee replacement

。　A patient had total knee replacement and two wound drains were placed during the operation.。　Both drains were removed on day 2. Post-operative X-ray on day 3 did not reveal any abnormality.。　On day 11, the patient was discharged.。　Two months later, the patient was admitted for prosthesis-related joint infection and open debridement was performed.。　A 1.5cm segment of drain was found inside the joint space and was removed.。　The patient was managed with a prolonged course of antibiotics.

Contributing factors:1. Exact cause of broken drain could not be identified.2. No documentation of details of the drain.

Recommendations: 1. Record details of drain, e.g. length, for reference to facilitate checking of completeness after removal. 2. Alert staff on the risk of broken instruments while reviewing post-operative X-ray.

Pre-Vac wound drain

Retained guide wire

。　A paediatric patient with multiple co-morbidities was admitted for chest infection.。　The patient deteriorated and required insertion of central line for inotropic support. 。　Nurse A asked nurse B for the checklist of “Insertion of Central Line with Guide Wire” for time-out.。　Nurse B was preparing urgent medication for the patient and did not hear nurse A.。　The doctor and the nurse A went on with the emergency procedure and did not follow the process of time-out.。　The procedure trolley was moved away before instruments had been counted and checked.。　Inotropes and intravenous fluid were given via the central line immediately.。　Occlusion alarm of the infusion pump beeped repeatedly.。　About 1.5 hour later, a guide wire was found in the catheter and it was removed.

Central venous catheter setincluding guide wire

Contributing factor:Staff did not comply with HA Safety Policy on Bedside Procedures.

Recommendations: 1. Alert staff to comply with the HA Safety Policy on Bedside Procedures. 2. Develop a mechanism to facilitate holding of guide wire, such as clamping with forceps.

2

Retained plain gauze in vagina

A pregnant lady, due for delivery, was admitted for suspected leaking.

In the pre-natal ward, a doctor performed speculum examination.

The patient was transferred to labour ward for induction of labour.

A piece of plain gauze was found in the vagina.

。Saw a pool of 　liquor obscuring 　the view.。Requested two 　packs (10 pieces) 　of plain gauze.。Used a sponge 　forceps to hold a 　pile of plain 　gauzes to absorb 　the fluid in the 　vagina repeatedly. 。Disposed the 　gauzes 　immediately after 　use.

Contributing factors:1. Unaware of the potential risk of retained gauze 　associated with speculum examination.2. Unaware of the safe practice to use one gauze at a 　time.

Recommendations: 1. Enhance awareness of doctors on surgical 　 counting and risk of retained gauze, even during a 　 non-surgical procedure. 2. Educate staff on the good and safe practice on 　 handling and clamping one plain gauze at a time.

Speculum set

Retained broken drain after spinal surgery

。　In 2009, a patient had elective surgery for spinal stenosis and 3 　　wound drains were placed during the procedure.。　Two drains were removed on day 1 and the remaining drain was 　　removed on day 4 of the procedure.。　On day 7, the patient was discharged and followed up at Specialist Out-patient Clinic (SOPC) regularly.。　In 2015, doctor suggested another spinal surgery to treat further 　　spine degeneration.。　During the operation, a 4cm broken piece of drain was found and 　　removed.

Perforated drain

Contributing factors:1. Exact cause of broken drain could not be identified.2. Detection of broken drain on X-ray was difficult.

Recommendations: 1. Avoid cutting the drain across the drainage holes. 2. Measure and document length of drain inserted in operative record. 3. Reinforce checking and documentation of completeness of drains upon removal. 4. Alert doctors of retained foreign body on reading post operative X-ray.

3

Sentinel Events

Retained K-wire fragment after wrist arthroscopy

。　A patient underwent wrist arthroscopic operation for an injury.。　Two 1.2mm diameter flexible K-wires were used in the procedure.。　The number and completeness of instruments were checked before and after use.。　Post-operative course was uneventful.。　A follow-up X-ray of the wrist taken at SOPC revealed a 1mm metallic foreign body.。　The foreign body was removed surgically and confirmed to be part of a K-wire.

Contributing factor:Failure to recognize the breakage of the tip of K-wire by naked eyes.

Recommendations: 1. Enhance awareness. 2. Consider additional measures e.g. use of magnifying glass when needed.

4

Inpatient SuicideIn Q3 2015, there were 2 inpatient suicide cases. The details of the two cases are outlined below.

Case 1。　A patient had stomach cancer with metastasis and 　　was admitted repeatedly for symptoms of sub-acute 　　intestinal obstruction.。　The patient was assessed by clinical psychologist and 　　palliative care nurse. No suicidal risk was noted. 。　Pain was assessed and managed accordingly and was 　　“acceptable” by the patient.。　The patient was granted home leave with pain 　　control medication (continuous morphine injection 　　via a syringe driver).。　The patient returned to the hospital for shortness of 　　breath on the next day.。　Two days later, the patient requested home leave 　　again which was granted. 。　The patient jumped from height on the same 　　evening.

Case 2。　A patient suffered from chronic pain and 　　depression was admitted to a psychiatric 　　hospital for suicidal attempt.。　The patient was mentally stable during 　　the hospital stay.。　Day leaves were granted since Day 10 　　after admission.。　6 months after admission, a day leave (9th 　　day leave) was granted for family 　　gathering.。　Patient was found fallen from height at 　　family’s home.

Conclusion:The RCA Panels found the assessment and care to the patients appropriate and made no recommendation.

OthersContaminated lung biopsy

。　Two patients had Computed Tomography guided lung biopsy performed in the Department of Radiology in the same morning. 。　Pathology reports confirmed both patients had the same type of lung cancer. 。　On subsequent assessment, one patient was referred to the Department of 　　Cardiothoracic Surgery in another hospital for further management. 。　The patient had surgical removal of the right lower lung lobe. Pathological 　　examination of the excised lung tissue revealed features of tuberculous 　　infection instead of lung cancer. 。　Contamination of the patient specimen which led to the wrong diagnosis was 　　confirmed by laboratory testing. Specimen bottle

with intact seal

Tissue wrapping station Tissue embedding

Contributing factors:The panel concluded that three factors might contribute to the contamination of the specimen, including biopsy collection, tissue wrapping and embedding in the laboratory.

Recommendations: 1. To ensure that specimen bottle will not be used once the seal is broken or removed, to eliminate the additional use of rinsing bottle for biopsy procedure, to label the specimen bottle once it’s designated to a patient and to enhance the documentation of specimen nature and quantity. 2. To stagger the sequence of handling specimen of similar nature whenever possible and to facilitate the ease of single use of forceps in tissue wrapping and embedding. 3. To ensure adequate checking and traceability in laboratory, including double checking mechanism for tissue wrapping and to ensure traceability in the entire specimen processing, in particular during tissue wrapping and embedding procedures.

5

Serious Untoward Events

There were 14 SUE cases reported in this quarter, 12 of them were medication errors and two were patient misidentification. The medication errors involved giving known drug allergens (KDA) to patients (6), use of hypoglycaemic agents (2), anticoagulant (1), inotrope (1), dangerous drugs (1), and others (1).

Of the 6 KDA, 3 developed mild symptoms which subsided after treatment. The others had no allergic reaction.

Medication ErrorKnown drug allergy

。　An old age home (OAH) resident was admitted for urinary tract infection.。　The OAH staff did not bring the patient’s Hong Kong Identity Card (HKID) for registration and the patient was registered with a pseudo-ID (UJ number) instead of HKID number.。　From OAH record, the patient had known allergy to penicillin.。　Doctors were not aware of the drug allergy and entered “No Known Drug Allergy” into the Clinical Management 　　System (CMS).。　Augmentin was prescribed via IPMOE and one dose of Augmentin was administered to the patient.。　Patient’s family brought the HKID to hospital for registration the next day.。　When the next dose of Augmentin was to be administered, a drug alert message popped up from the IPMOE 　　system.。　The patient did not suffer any allergy reaction from the first dose of Augmentin.

Contributing factors: 1. The drug allergy card was not prominently displayed in patient’s record folder. 2. Allergy checking was missed by doctors and nurses.

Recommendations: 1. Display prominently the drug allergy card in patient’s record folder. 2. Reinforce compliance to allergy checking before drug prescription and administration. 3. Alert staff the risk of delinking clinical information, such as drug allergy, for patient bearing pseudo-ID.

Risk of Pseudo-ID

　　　　　。If patients cannot present any valid identity document but claimed to be a HKID card holder upon registration, they will be registered under a Pseudo-ID.　　。In CMS, an orange button “Check ID” will be turned on under both Pseudo-ID and claimed-HKID to alert　staff.

　　　。Staff could access the linked records via this button but the clinical information, including the allergic　　　　history, is not automatically transferred, until the records are merged after patients’ identity has　　　　　　been verified.

6

Patient Misidentification

Off drain as plannedthen home

Doctor, please removeabdominal drain frompatient A – bed 28.

Okay. Let me write downon my palm as reminder.

Case nurse of patient Ais busy. Another nursewill assist you.

Doctor E went to bed 28X.

Management plan on medical notes of patient A – bed 28 & B – bed 28X.

Plan off pigtail mane if↓ effusion

NURSE STATION28

Okay.

Bed 28XBed 28

1

3

5

2

4

6

NURSE STATION

Isn’t the position ofthe abdominal draintoo high?

???The nurse came to bed 28X to assist the doctor.

Bed 28XBed 28

7

Bed 28XBed 28

Without checking patient’s identity, doctor removedthe chest drain from patient B - bed 28X.

Bed 28XBed 28

This is NOT bed 28!

I’m going to removethe drain from you.

8

Contributing factors:1. Lack of clear process and standard procedure on 　patient identification for bedside procedures.2. Not comply with patient identification checking 　before drain removal.3. Ineffective communication and clinical handover 　among clinical team.

Recommendations:1. Standardize the management of surgical drains or catheters at the hospital level.2. Reinforce “Time out” before procedures.3. Strengthen staff training on correct patient identification and procedural safety.

7

EDITORIAL BOARDEditor-in-Chief: Dr Rebecca LAM, CM(PS&RM), HAHO

Board Members: Dr N C SIN, SD(Q&S), KEC; Dr Tony MAK, SD(Q&S), KWC; 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

Local Sharing

Surgical fire

。　A patient had facial surgery done under monitored anaesthesia care (MAC).。　During the procedure, 2L/minute oxygen flow was delivered through a nasal cannula.。　Anaesthetist punctured the nasal cannula through a 14G angiocatheter for carbon dioxide monitoring. 。　Aqueous hibitane was used as skin preparation.。　Monopolar diathermy pen was used for haemostasis near the nasal area and a spark was generated accidentally 　　causing a surgical fire. 。　The patient sustained 6x4cm second degree burn around the nasal area. The surgeon also had superficial burn on 　　both palms.

Contributing factor:Monopolar surgical diathermy was used in close proximity to an oxygen-enriched environment.

Recommendations: 1. Avoid the use of monopolar diathermy during operation at close proximity to an open supply of oxygen. 2. Establish a cluster-wide guideline to prevent surgical fire.

Wish you a healthy, happy & safe Year of the Monkey!

Greetings from Director(Q&S), Cluster Service Directors(Q&S) and editorial board

安全大吉