ISSUE 27 OCT 2012A Risk Management Newsletter for Hospital Authority Healthcare Professionals

CCE’s Perspective on Risk Management

§ Sentinel Events (Q2 2012) 。Wrong Site Operation。Retained Consumables & Instrument。Maternal Death or Serious Morbidity Associated

with Labour or Delivery。Patient Suicide

IN THIS ISSUE§ Serious Untoward Events。Serious Untoward Events (Q2 2012)§ Global & Local Sharing。Global Sharing on Safety in Maternity Services。Top Reported Categories of AIRS Incident (Jan - Jun 2012)

RISK ALERT

Over the years, HAHO and Clusters have made tremendous efforts in organizing numerous training programs and initiatives to promote incident reporting, root cause analysis, risk management and share good practices in patient safety. Today, while we can proudly say that we have already established a solid foundation and thriving culture in incident reporting as a means to improving quality and safety, it is imperative for us to continue to leverage on the intrinsic good values and benefits of incident reporting not only for actualoccurrences but also near misses, i.e. errors that could have harmed patients but were intercepted before affecting them. Learning from factors contributing to the occurrence of such near misses or incidents, and taking actions to control/eliminate their underlying root causes are the main keys to improving patient safety. Our easily accessible and low-burden reporting system can definitely enhance staff's willingness to report near misses.

"To err is human". This makes healthcare industry particularly challenging, similar to other High ReliabilityOrganizations and high risk industries like aviation. Hierarchy, or status-derived power distance, which often inhibits people from speaking up, is a prominent risk factor for impeding team performance. It is verygratifying for me to see the progress of Communication and Teamwork training in some hospitals to build up a speak-up culture. While human errors cannot be totally eliminated, highly effective teamwork and speak-up culture are indeed crucial to enhancing patient safety in our daily work.

Lastly, I would like to take this opportunity to thank our colleagues for their immensededication and effort in maintaining patient safety at all times and building a culture for continuousimprovement. This will enable us to move towards our corporate vision of being “Trusted by ourCommunity”.

Dr. Chor Chiu LAU, Cluster Chief Executive, Hong Kong East Cluster

DISTRIBUTION OF SENTINEL (SEs) & SERIOUS UNTOWARD EVENTS (SUEs) (Q2 2012)

SENTINEL EVENTS Q2 2012

Case 1: Local Anaesthetic (Lignocaine) was Injected to the Wrong Eye during Retrobulbar Anaesthesia • The patient was admitted for elective repair of retinal

detachment of the LEFT eye under retrobulbar anaesthesia. • The operation site was marked above the patient’s LEFT eyebrow. • Sign in and “time out” were performed by the surgeon and the nurse.• The surgeon prepared the anaesthetic drug (2% lignocaine) and

injected to the retrobulbar space of patient’s RIGHT eye instead ofLEFT eye.

• The surgeon was informed that the anaesthetic drug was given tothe incorrect eye.

• The surgeon subsequently injected the anesthetic drug andperformed operation on the patient’s LEFT eye uneventfully.

• The patient’s RIGHT eye was assessed and no harm was detected.

Case 2: Removal of Left instead of Right Double J (JJ) Stent• The patient has history of bilateral hydronephrosis with JJ

stents in situ on both sides. The patient was scheduledfor removal of RIGHT JJ stent only.

• Dr. A checked the case notes with Nurse B and noted that removal of RIGHT JJ stent under flexible cystoscopy (FC)was planned.

• Dr. A performed “time out” with the patient and nursesbefore the procedure.

• Dr. A confirmed the side (RIGHT) of the JJ stent to be removed.• Dr. A found it difficult to obtain a good view due to tangling

of both JJ stents, presence of turbid urine and deformity ofbladder during the procedure.

• Dr. A removed the JJ stent incorrectly after tracking up theLEFT ureteric orifice.

• Post procedure X-ray revealed the LEFT JJ stent was wrongly removed.

• The LEFT JJ stent was subsequently reinserted and RIGHT JJstent was removed uneventfully.

Case 3: Spinal Surgery at Wrong Level• The patient has lumbar spinal stenosis, admitted for L4

laminectomy and L4/5 decompression.• “Time out” was performed prior to confirming the spinal

level by the use of intra-operative X-ray with metal markerson L4. The markers were subsequently removed beforelaminectomy.

• The surgeon removed the presumably L4 lamina (L4laminectomy).

• Before proceeding further, the team performed second“time out” and found that laminectomy was performedon L3 instead of L4.

• The operation was subsequently revised and the correct surgery was performed in the same session.

Contributing Factor:Long time lapse between “time out” and injection of localanaesthetic.

Recommendations:1. To inject local anaesthetic

immediately after completing “time out”.

2. To consider performing “time out” again just beforeinjection of anaesthetic and before incision.

Contributing Factors:1. Deformity of bladder increases

difficulty of the procedure.2. Unfamiliarity with the procedure.

Recommendations:1. To seek seniors’ advice when

performing unfamiliar procedures or encountering complicatedsituations.

2. To use fluoroscopic guidancewhen performing difficult cases.

Contributing Factors:1. Absence of markings to assist the

surgeon to identify the spinal levelfollowing removal of the metalmarkers after X-ray screening

2. No independent confirmation of correct operation site by another staff.

Recommendations:1. To use fixed marking (e.g. diathermy

to mark the lamina; make a cut tothe lamina) to identify the correctoperation site

2. To confirm correct operation siteby another staff independently.

P.2

WRONG SITE SURGERY / INTERVENTIONAL PROCEDURE

Case 1: Retained Intravascular Guide Wire• A post craniotomy patient developed low blood pressure, requiring

insertion of a central venous catheter(CVC).• 2 doctors and 1 assisting nurse performed the procedure.• The supervising doctor had to answer an urgent phone call during the

procedure.• After completion of the procedure, the guide wire was found missing.• X-ray imaging revealed that the guide wire was retained in the

patient’s central vein.• The guide wire was retrieved uneventfully.

Contributing Factors:1. Lack of hands-on training and assessment of the competency of the newly joined resident in performing

CVC insertion.2. Bedside procedures safety checklist was not followed effectively. The checklist was signed without

eye-witnessing the removal of the guide wire from the patient’s body.

Recommendations:1. To reinforce the training and assessment of competency of trainees.2. To strictly enforce safety measures for removal of guide wire: e.g. “guide wire out” should be voiced out

with acknowledgement; and assisting nurse should only connect fluid lines after confirmation of guidewire removal.

Case 2: Retained Metallic Foreign Body in Patient’s Knee Joint • The patient was suffering from right knee osteoarthritis and was admitted for elective surgery.• Arthroscopic removal of loose body was done and the patient was discharged 2 days later.• The patient attended AED 4 days after discharge because of increasing pain and swelling on right knee and

leg.• The patient was readmitted for further management of radio-opaque signal at posterior aspect of joint.• Upon rechecking the instruments used in the last arthroscopic removal, a metallic covering defect at the

end of the 70˚ telescope was found. The shape and size ofthe defect was compatible with the image shown in X-raysand CT scan.

• Right knee arthroscopic removal of foreign body wasperformed.

• The patient’s recovery was uneventful.

Contributing Factors:1. Difficulty in detecting defect of delicate instruments by naked eyes.2. Low awareness of staff on checking the integrity of instruments after use.

Recommendations:1. To use LED Hand Magnifier to facilitate checking and inspecting the integrity of delicate instruments

after use in operating theatre.2. To document details of scopes used in surgical operations into the operating record book.

P.3

SENTINEL EVENTS Q2 2012RETAINED CONSUMABLES / INSTRUMENTS

P.4

SENTINEL EVENTS Q2 2012RETAINED CONSUMABLES / INSTRUMENTS

Case 3: Retained Gauze in Patient’s Wound after Marsupialization• A patient underwent an emergency marsupialization operation for left Bartholin’s abscess. A piece of

soaked gauze was packed in the patient's wound which was then covered with a pile of gauzes.• The packed gauze was documented in operation record and post-operative order in the patient’s record.• The operating theater nurse handed over the wound packing information to the ward nurse.• On the next day morning round, the patient told the surgeon that a mass had fallen off and was discarded.

The surgeon inspected the wound and subsequently discharged the patient.• Two days later, the patient attended AED for persistent wound swelling and pain. No wound examination

was conducted and the patient was discharged with a course of antibiotics. • One week later, the patient was admitted via AED for persistent wound swelling with discharge.• A piece of gauze was found retained inside the patient’s wound and was removed.• The patient’s condition improved and the patient was subsequently discharged.

Contributing Factor:Failure of thorough wound examination.

Recommendations:1. To perform a manual examination of post-operative packed

wound.2. To conduct a proper wound examination for patients with

post-operative symptoms and complications.

Case 4: Retained Scleral Plug after Left Eye Vitrectomy• The patient who suffered from rhegmatogenous retinal detachment

and cataract of the left eye was admitted for elective vitrectomy andendolaser to retina.

• A scleral plug was found missing during the operation.• The operative site was searched twice but the missing scleral plug

could not be located.• The patient was discharged to ward but the scleral plug could not be

found despite thorough search in the operating theatre. • X-ray orbit of the patient showed a shadow compatible with the

missing plug.• A subsequent operation was performed to remove the patient's

retained scleral plug on the same day.

Contributing Factors:1. Low staff’s alertness on potential risk of retained foreign body (FB) within the surgical field as

small items of “surgical material” were commonly found missing and subsequently foundoutside the surgical field afterwards.

2. Difficulty to manually locate dislodged scleral plug into deep space of the orbit. Recommendations:1. To promote high index of suspicion among staff for missing “surgical material’ inside the surgical field. 2. To draw up a department specific safety notes for dealing with missing “surgical material” as future

intra-operative reference.

P.5

SENTINEL EVENTS Q2 2012MATERNAL DEATH OR SERIOUS MORBIDITY ASSOCIATED WITHLABOUR OR DELIVERYCase 1: Maternal Death with Primary PostpartumHaemorrhage & Genital Tract Trauma• The patient gave birth to a normal baby girl by

normal vaginal delivery. • Soon after delivery, the patient developed

postpartum bleeding and cervical tear wassuspected by the attending midwife.

• The on-call medical officer, a resident specialist,and an associate consultant were called forassistance.

• To manage the persistent oozing and massiveblood loss, a total of three operations wereperformed for the patient in the obstetric OT andmain OT subsequently.

• Despite all treatment, the patient's conditioncontinued to deteriorate and the patienteventually succumbed.

Case 2: Serious Morbidity Associated with Delivery• The patient underwent emergency Lower

Segment Cesarean Section for threatenedpreterm labour and small preterm twins.

• The operation was uneventful and two normalhealthy babies were delivered.

• Soon after delivery, the patient complained ofheadache. Her blood pressure was noted to behigh. No proteinuria was detected.

• The patient later reported that her headache hadmuch improved. Her blood pressure had returnedto normal after she was given 2 bolus injection ofantihypertensive drug.

• The patient’s conscious level deteriorated 2 hourslater. She developed up-rolling eyeball and wasnoted to have hypertension. Her CT brainrevealed acute intracranial haemorrhage.

• The patient underwent an emergencyneurosurgical operation followed byrehabilitation care afterward.

Concluding Remarks by Investigation Panel:1. The occurrence of retroperitoneal haematoma

in the patient was rare and it was difficult todiagnose.

2. Panel members appreciated the efforts ofboth the doctors and nurses who demonstratedhigh quality teamwork and spirit in managingthe patient’s emergency situation.

Concluding Remarks by Investigation Panel:1. The care provided by the clinical team to this

high-risk pregnancy patient was consideredtimely and appropriate.

2. It is recommended that more support andsupervision by senior staff would bebeneficial in the management of patientswith obstetrical emergencies.

PATIENT SUICIDEFour patients committed suicide in the 2nd quarter of 2012, including 2 psychiatric inpatients, 1 psychiatric patient on home leave and 1 inpatient from isolation ward.

Highlights of the Inpatient Suicide Casefrom Isolation Ward:• It was decided that the patient be

placed in an isolation room for diseasemanagement.

• A doctor explained the need forisolation care to the patient andemphasized that the disease conditionwas curable.

• The patient accepted the explanationand was emotionally calm andco-operative with healthcare personnel.

• Three days later, the patient was foundhanging himself on the wall-mountedshower sliding bar using a face towel inthe isolation room toilet.

Contributing Factors for 4 Suicide Cases:1. Underlying illness of the patient.2. Unawareness of staff on environmental patient suicidal

risks.3. Solitude of patients accommodated in single room,

isolated from others.Major Recommendations for 4 Suicide Cases:1. Modify the shower facility in isolation room to reduce

suicidal risk.2. Perform regular psychological and emotional assessment

for patients who are being cared for insideisolation room.

3. Review the quality and standard of CCTV system andimprove its image visibility of patients under surveillanceeven under dim light.

4. Review the security measures at the hospital main exitto safeguard against patients slipping through the hospitalexit to leave the hospital by way of following visitors.

P.6

SERIOUS UNTOWARD EVENTS Q2 2012A total of 26 SUE cases were reported in the second quarter of 2012, of which 23 were related to medication errors and 3 to patient misidentification. The breakdown of all these medication error cases was:10 “Known Drug Allergy”,2 “Use of Dangerous Drugs”,1 “Use of Muscle Relaxant”,2 “Use of Anticoagulants”,2 “Use of Insulin”,1 “Use of Oral Hypoglycaemic Agent”,1 “Use of Electrolytes”, and4 “Use of Other Medications”.

CASE HIGHLIGHTS ON KNOWN DRUG ALLERGY (KDA)

Known Drug Allergy (10)

Administration of Naproxen to a Patient Allergic to Diclofenac• The patient had a history of drug allergy of 4 drugs

including Diclofenac.• The patient attended AED with a complaint of right

knee pain. ‘Diclofenac’ entered as free text ‘Diclofen’in CMS.

• The triage nurse wrote down “Bromhexine” and“Diclofen” allergy on the AE card, stamped the “drugalert” chop, and filed the Clinical Summary Printoutinto the AE record.

• The attending doctor had not paid attention to thepatient's pop-up drug allergy information in the CMSand closed the box.

• 3 drugs, including Naproxen, were prescribed to thepatient. Since this prescription was not noted by the Pharmacy staff, Naproxen was dispensed to the patient.

• In the same evening, the patient was brought back toAED in serious condition requiring intubation andmechanical ventilation.

• The patient was admitted to ICU with a diagnosis ofserious allergic drug reaction. The patient was treatedaccordingly and was discharged to home 9 days later.

During this reporting period, it was noted that a number of patients who were prescribed and administered KDA drugs had developed allergic reactions including generalized rigidity, skin rash over the body, bilateral eyelid oedema and itchiness.

Overall Contributing Factors for all 10 KDA cases:1. Staff’s sub-optimal alertness to the need for checking patients’ drug allergy status.2. Staff's knowledge deficiency to recognize cross-sensitivity among drug classes.3. Staff's unawareness of the Medication Decision Support (MDS) behavior in handling “free-text”

information whereby “free-text” entry would not be subject to system checking on drug allergy.

Major Recommendations for all 10 KDA cases:1. Reinforce the practice and monitor staff compliance on mandatory checking of drug allergy history

before drug prescription and administration.2. Introduce the topic of ‘System Behavior and Pitfall of MDS’ in orientation program of medical, nursing

and pharmacy staff to enhance awareness of system behavior and its limitations on allergyinformation management.

3. Check existing free text entry allergy records in CMS to proactively reassess and re-convert free text intosystem information where possible to enhance CMS checking ability for patients' drug allergy.

P.7

Wrong Dose of Muscle Relaxant was Administered to Patient• Rocuronium infusion in concentration of 1mg/ml

at 10ml/hour was prescribed. The infusion ratewas subsequently increased to 18ml/hr.

• Rocuronium infusion of 10mg/ml (10 times ofintended concentration) was administered to thepatient for about 3 hours.

• The incident was discovered when the Pharmacyenquired about the abnormal increase inRocuronium consumption.

• The patient’s condition was stable with noresidual muscle weakness observed in thepatient.

Contributing Factors:1. Uncommon prescription of Rocuronium

infusion in this clinical unit.2. Exact concentration of preparation was not

explicitly described.Recommendations:1. To adopt the practice of alerting all staff in the

same / next shift for any uncommonly usedmedications or specific preparation formedication for patients.

2. To regularly update the ‘Standard DilutionChart’ for commonly used medications’preparation.

3. To reinforce training and encourage staff toconsult their seniors or pharmacists for anyuncommonly used medication or preparation.

Gliclazide Tablets was Dispensed instead ofMetoprolol as Prescribed• A patient with history of uncomplicated

hypertension and lipid disorder was prescribedwith Metoprolol 25mg bd.

• A Dispenser wrongly picked Gliclazide 80mginstead of Metoprolol 50mg tablets.

• The patient unknowingly took Gliclazide 40mgtwice a day and experienced occasionaldizziness. The patient’s blood pressure wasraised to 197/112 mmHg.

• At a subsequent follow-up, the patient wasprescribed Metoprolol 50mg again because of hisuncontrolled BP. The patient noticed a differencein the appearance of the medication from theprevious stock. The drug was hence returned tothe Pharmacy. Then the dispensing error wasdiscovered.

Contributing Factors:1. Failure of pharmacy staff to comply with the

‘3 checks’ during the dispensing procedure.2. Difficulty in differentiating the two drug

preparations as they were both white tablet ofsimilar size in strip pack.

Recommendations:1. To arrange daily duty rotation of pharmacy staff to

minimize concentration lapses due to repetitiouswork.

2. To establish Standard Operation Procedures fordrug dispensing in the GOPC setting to ensure thatdouble checking of prescription and ‘3 checks’procedures are in place.

3. To place strip packs, with the face showing drugnames but NOT with the white tablets showing faceup, so as to facilitate checking at the point ofpicking up the medication.

Inappropriate Conversion Ratio for Morphine• The patient, who had an advanced hepatocellular

carcinoma, was prescribed oral Morphine 6 mgQ4H (i.e. total of 36mg each day) for pain relief.

• Since the patient refused oral medication, Dr Adiscontinued the oral Morphine and prescribedcontinuous subcutaneous infusion with Morphine40mg Q24H via syringe driver. (Note: SubcutaneousMorphine 40mg Q24H is equivalent to a total doseof 80 mg oral Morphine daily).

• The patient became sleepy and drowsy in thefollowing 24 hours.

• Physical examination of the patient showedevidence of morphine overdose.

Contributing Factor:Not following conversion guidelines in prescribing Morphine for subcutaneous route.Recommendations:1. To enhance the system for clinical staff to make

the correct dosage conversion when the route ofadministration is changed for strong opioids.

2. To set up a system of close vital sign monitoringafter starting of strong opioids.

SERIOUS UNTOWARD EVENTS Q2 2012

TOP REPORTED CATEGORIES OF INCIDENTS IN AIRS (JAN - JUN 2012)

EDITORIAL BOARDEditor in-chief: Dr. Tak Yi CHUI, Chairman of CC(Q&S)

Board Members: Dr. Tony KO, CM(PS&RM), HAHO; Dr. Clarence LAM, HKWC Service Director(Q&S) / QMH CONS(HAE); Dr. Petty LEE, P (CPO), HAHO; Dr. Y W TSANG, KCC SD(Quality & Safety) / QEH CON(Path); Mr. Fred CHAN, SM(PS&RM), HAHO; Ms. Katherine PANG, M(PS&RM), HAHO.

Advisor: Dr. Lawrence LAI, HOQ&S Honorary Senior AdvisorSuggestions or feedback are most welcome. Please email us through HA intranet at address: HO Patient Safety and Risk Management Department

• Incident reporting in AIRS isvoluntary

• Medication cases include near miss incidents without affecting patients.

GLOBAL SHARING ON SAFETY IN MATERNITY SERVICES

In the last issue of HARA, maternal mortality was discussed based on the World-wide trend figures. In this issue, the focus moved to improvement measures. The King’s Fund from UK recently published on the web a toolkit that may be useful for reference.

Improving safety in Maternity Services – A toolkit for teams (The King’s Fund)

The King’s Fund launched an independent inquiry into the safety of maternity services in 2006. Based on the recommendations from the inquiry and in partnership with the Royal College of Obstetricians andGynecologists, the Royal College of Midwives, the NHS Litigation Authority, Centre for Maternal And Child Enquiries and the National Patient Safety Agency, The King’s Fund launched the Safer Births Improvement Programme, providing customized support to 12 multidisciplinary maternity teams in England. This toolkit shares the experiences and lessons from those teams and consists of five key areas for improvement in maternity care including: 1. Team working;2. Communication;3. Training;4. Information and guidance;5. Staffing and leadership.

Ref: http://www.kingsfund.org.uk/publications/maternity_safety.html

LOCAL SHARING