ISSUE 28 JAN 2013A Risk Management Newsletter for Hospital Authority Healthcare Professionals

§ Sentinel Events (Q3 2012) 。Retained Consumables and Instrument。Patient Suicide。Other Adverse Events§ Serious Untoward Events (Q3 2012)

IN THIS ISSUE§ Sharing。Do Hospital Incident Reporting Systems

Capture Most Patient Harm?。Tips for Medication Safety。Medication Incident Statistics (Jan - Jun 2012)

RISK ALERT

SD’s Perspective on Risk Management

During the hospital accreditation surveys, we have been repeatedly asked by the surveyors what we have done to minimize under-reporting of incidents in the hospitals. Although reporting to the Advance Incident Reporting System (AIRS) is mostly voluntary, we have seen an encouraging increase in AIRS entries, reflecting successful inculcation of the reporting culture throughout the organization. Some minor issues notwithstanding, we are proud of AIRS which has been specifically designed to alert various stakeholders of the occurrence of incidents encountered in our daily practice. As responsible professionals, we would certainly like to submit our incident reports to AIRS with all accurate facts, causes, mitigating and improvement actions, sometimes forgetting that this might take quite a while and defeat totally the purpose of AIRS: to alert. We have to remember and remind ourselves that the effectiveness of AIRS hinges on early reporting. For Sentinel Event (SE), there is of course a corporate policy to ensure early reporting. A factual account is of pivotal importance in dealing with this category of incidents. While we are fully aware of the distress of the involved colleagues, let us not forget that a detail and accurate factual account is the best way to protect them and facilitate the management in managing Sentinel Event. Since it is still early days in the New Year, may I wish you all a very fruitful but peaceful 2013!

Dr. Clarence LAM, HKWC Service Director(Q&S)

DISTRIBUTION OF SENTINEL (SEs) & SERIOUS UNTOWARD EVENTS (SUEs) (Q3 2012)

SENTINEL EVENTS Q3 2012

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4 CASES OF RETAINED GAUZE IN VAGINA AFTER EPISIOTOMY REPAIR

Case 1: Patient A attended AED and delivered a baby with complications of broken cord and retained placenta during the process.Subsequently, the retained placenta was delivered completely.She had persistent foul smelling lochia after discharge from hospital.A piece of gauze was removed in a mainland hospital.

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Case 2: Patient B gave birth to a baby by normal vaginal delivery.She attended the Maternity and Child Health Centre for post-natal check-up.A piece of gauze was found and removed during vaginal examination.

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Case 3: Patient C gave birth to a baby by normal vaginal delivery.She attended a private hospital because of something protruding out from vagina.A piece of gauze was found and removed.

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The doctor changed the practice and packed the whole piece of gauze into the patient’s vagina to prevent blood from blocking the site for wound repair.

Case 4: Patient D gave birth to a baby by vacuum extraction.During episiotomy repair, the resident explained to the patient the finding of a bluish mark (later confirmed a birth mark) on the baby’s chest. The resident continued the wound repair while having the conversation with the patient.The patient had increasing wound pain and smelly lochia. She subsequently attended a private clinic.A piece of gauze was found and removed in the course of vaginal examination.

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Contributing Factors:Failure in proper counting of long gauze after episiotomy repair.Unaware of risk to pack the whole piece of gauze in vagina during episiotomy wound repair.Failure to detect and remove packed gauze by vaginal examination after wound repair.

Recommendations:Improve the counting system

Ensure double counting of the gauzes used for the episiotomy repair independently by the operator and another staff;Document the quantity of gauzes on the counting form immediately after unpacking;Enhance the design of the gauze counting form and use clearer wordings in the form.

Remind staff to be vigilant when performing post-wound repair vaginal examination to exclude the possibility of retained foreign objects.

Strengthen the training and supervision of doctorsEstablish a structured assessment of interns on episiotomy repair;Empower staff to alert the interns’ supervisors should they detect any deviation from normal practice;Reinforce safety awareness regarding surgeries and clinical procedures, including the importance of counting and risk of item retention.

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Three home leave patients and hospital inpatient committed suicide during the 3rd quarter of 2012.

One inpatient with chronic illness committed suicide by tightly wrapping a transparent plastic bag over the head. One patient with mental illness committed suicide during hospital stay by hanging. Another patient with mental illness committed suicide during home leave by falling from height.

The patient was admitted for elective surgery to remove a broken wire after fixation of fracture patella done in 2008.The operation was performed under spinal anaesthesia.A residual wire segment of the broken wire was noted in a post operation x-ray.Another operation was scheduled under local anaesthesia on the following day to remove the 1.5cm residual wire segment.The patient recovered uneventfully.

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Contributing Factors:Difficulty in confirming the completeness of the used broken tension band wire during removal.Low awareness of staff on checking the number of broken fragments to be taken out during operation.

Recommendation:Perform routine x-ray before reversal of patient to ensure complete removal of broken wire in “multiple-fragments” cases.

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Recommendations:Develop a practice of continuous assessment of suicidal risk of patients during their hospital stay especially for those with changing condition.Enhance training of staff on suicidal risk identification and assessment.Put up bed-side suicidal caution signage (in a format only recognizable by staff) to further alert staff on need for close observation of at-risk patients.Recommend enhanced environmental scanning to identify high suicidal risk patients through departmental patient safety rounds.

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Key Contributing Factors:Underlying medical conditions (e.g. chronic or terminal illness) and mental health conditions (e.g. depression).Staff’s unawareness of environmental risks for patient suicide (e.g. door knob).Determination of patient to end own life. This could mask the patient’s depression and suicidal ideas. The patient could be seen to be in a calm and stable mood.

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SENTINEL EVENTS Q3 2012RETAINED SEGMENT OF BROKEN TENSION BAND WIRE

PATIENT SUICIDE

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SENTINEL EVENTS Q3 2012

The patient was transferred from Hospital A to

Hospital B for further treatment of acute

myocarditis and slow heart rate.

OXYGEN DELIVERY TUBING WAS FOUND NOT CONNECTED TO THE EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) SYSTEM

Contributing Factors:Inadequate communication following the change of practice in the connection of ECMO support system upon transfer of patient.Inadequate understanding of some staff members regarding tubing connection of the ECMO system.Insufficient alarm volume of oxygen saturation analyzer (48.5 – 52 dB) to alert staff in the ward with ambient noise level of around 50 – 70 dB.

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Recommendations:Establish communication structure to endorse changes in practice and ensure staff understanding on the changes.Enforce the arrangement for perfusionists or ECMO leaders to assist in between-floor transfer of patients.Update the patient transfer and handover checklists for patients undergoing ECMO treatment, including the checklists on different modes of set up and critical steps in connecting the ECMO system.Enhance staff training on the use of ECMO machine.Explore the procurement of purpose-built oxygen saturation analyzer with louder alarm.

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In view of the patient’s deteriorating condition 2 days after admission, the patient was transferred to the operating theatre for insertion of a catheter to connect with the life support ECMO system.

Following the operation, the patient’s condition further deteriorated after transfer to the Cardiothoracic Surgical Intensive Care Unit for continuous monitoring and treatment.

On examination, it was found that the oxygen tubing was not connected to the ECMO system. The tube was immediately reconnected by staff to improve the patient’s blood oxygen saturation.

However, the patient’s heart function showed no

subsequent improvement and the patient was

certified dead on the 6th day of admission.

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SERIOUS UNTOWARD EVENTS Q3 2012A total of 23 SUE cases were reported in the 3rd quarter of 2012, of which 22 were related to medication errors and 1 to patient misidentification. The breakdown of all these medication error cases was:8 “Known Drug Allergy”,3 “Use of Dangerous Drugs”,2 “Use of Anticoagulants”,2 “Use of Insulin”,2 “Use of Oral Hypoglycaemic Agent”,1 “Use of Oncology Drug”, and4 “Use of other medications”.

CASE HIGHLIGHTS ON KNOWN DRUG ALLERGY (KDA)Paracetamol was Prescribed and Administered to a Patient with Known Allergy to Dologesic

The patient was admitted for sudden onset of bilateral lower limbs weakness, asymmetry of mouth, headache and slurred speech.Dr. A wrote down the known drug allergy of Sulfonamide and Dologesic on patient’s Medication Administration Record (MAR) according to the Clinical Management System (CMS).The patient complained of headache and Dr. A prescribed Paracetamol 500mg as requested. The first dose of Paracetamol was obtained from ward stock cupboard. It was then administered by Nurse B to patient immediately after the doctor’s prescription.The incident was discovered by the pharmacist when the MAR was faxed to the Pharmacy requesting the supply of another medication.The patient had mild redness and itchiness over the right trunk.Paracetamol was discontinued at once and IV Piriton was given.The patient’s condition was stable and allergic symptoms subsided. The patient was discharged 3 days later.

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During this reporting period, it was noted that a number of patients had developed allergic drug reactions presenting with symptoms and signs such as rash over face, trunk and limbs, skin itchiness, swelling over both eyes and chills and rigor.

Overall Contributing Factors for the 8 KDA cases:Low staff alertness to drug allergy when using department protocol-driven medications.Inadequate experience – staff might not be on high alert for drug allergy problem when administrating Paracetamol.Non-compliance with standard drug prescription and administration practices.Inappropriate filing of clinical summary printout only as a loose sheet into AED folder resulting in doctors overlooking the information.

Major Recommendations for these KDA cases:Reinforce staff compliance with the practice of verifying patients’ allergy status during drug prescribing and administration. Conduct compliance audit on drug administration.Remind staff to fax all MARs of all drugs including ward stock to the Pharmacy for vetting. Develop a list of Common Over-The-Counter and Compound Preparations containing Paracetamol (Acetaminophen) and / or Aspirin (Acetylsalicylic Acid) and / or Aspirin like ingredients, and upload the list to hospital / cluster website for staff reference.Review orientation and training programmes to incorporate KDA and emphasize lessons learned by sharing reported KDA incidents.

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SERIOUS UNTOWARD EVENTS Q3 2012CASE HIGHLIGHTS OF OTHER MEDICATION INCIDENTSIV Clarithromycin was Given as IV Bolus

The patient was transferred from another hospital for continuation of care for pneumonia.Patient developed high fever and intravenous Clarithromycin was prescribed.4 doses of IV Clarithromycin was administered twice daily at the patient’s left foot venous site. The venous site was subsequently changed to the patient’s left hand .After administering the 2nd dose of IV Clarithromycin on left hand, acute left hand swelling & bluish discoloration around the intravenous site with rapid progression was noted.Retrospectively, it was discovered that the rate and dilution of IV Clarithromycin administered to the patient was incorrect since the 1st dose. Instead of the recommended dilution of Clarithromycin with 250ml of injectable water for the 60-minute infusion, 500mg Clarithromycin was diluted in 10ml water for injection and given as bolus over 3 minutes. As a result, 6 doses of Clarithromycin were inappropriately given.

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Contributing Factors:Misinterpretation of proper dilution method by staff before drug administration.Inappropriate assumption that the previous dilution method was correct, resulting in continuation of same dilution practice in administration of subsequent doses.Failure to correlate Klacid (trade name) and Clarithromycin (generic name) during cross checking with Cluster Dilution Recommendation Table.

Recommendations:Remind staff of the need to read the instruction leaflet carefully when handling uncommon medications and to consult senior staff / prescribing physician / pharmacist if in doubt.Reinforce staff on the importance to clarify unclear medication with pharmacy and if necessary consult Cluster pharmacy outside office hours.Remind staff to use generic name of drug in daily practice.

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Factor IX was Prescribed instead of Factor VIII to a Patient with Haemophillia AAn adult Haemophillia A patient on self-administered Factor VIII when necessary.An attending doctor erroneously prescribed Factor IX (Prothrombinex-HT) instead of Factor VIII during a follow-up visit.Prothrombinex-HT was out of stock. A pharmacist recommended another Factor IX (Prothrombinex-VF) preparation to the doctor, the prescription was changed accordingly. During the process, both the pharmacist and the doctor did not realize the error.The patient noticed the newly prescribed drugs and the leftover stock drugs at home were different.The patient returned to the pharmacy for clarification the next day. The patient claimed that one pharmacy staff told him that there was no difference. However, no pharmacy staff could recall the patient’s enquiry and there was no documentation.During one episode of bleeding, the patient found that the newly dispensed product was not effective in stopping bleeding and reverted to using the stock product thereafter.The patient reported the error in a follow-up visit two months later.

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Contributing Factors:Complex Medication Order Entry (MOE) screen.Prescription history not readily displayed on the dispenser’s screen.Lack of a clear workflow in handling patient’s enquiry.

Recommendations:Enhance the MOE function: only factor VIII can be prescribed to Haemophilla A patient and vice versa for Haemophillia B patient requiring Factor IX.Improve the process and documentation in handling patient’s enquiry.

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Recently there were a few reports in the local media about “delay of reporting” in HA. Incidentally, I come across a Report of the Office of Inspector General, US Department of Health and Human Services entitled “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm” and published in January 2012. What an alarming title!! Knowing that the context is in the US, I have extracted some observations and comments as food for thoughts for colleagues. “Hospital staff did not report 86% of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm.” “Reported patient safety incidents could include adverse events, ‘near misses’ or situations with the potential to harm patients (‘unsafe condition’).” “Advantages of incident reporting systems: system’s familiarity among hospital staff, advantages derived from involving frontline personnel in identifying safety hazards for the organization, thought as a system to capture a wide range of events at a lower cost to hospitals comparing to other event detection methods.” “Limitations of incident reporting systems: it can be difficult to determine incidence rates based on reported data because of variability in the rate and consistency of reporting, research suggests that incident reporting systems capture only a small percentage of adverse events and that some categories of events are underrepresented.” “Hospital accreditors view incident reports within the context of larger hospital quality and patient safety efforts. Surveyors are most likely to review the results rather than review the methods used to track hospital adverse events.” Suggestions:

Potential patient harm could be viewed from a broader perspective, including loss of clinical specimens, material containing patient personal data, etc.Incident reporting IT system is ONLY PART OF the reporting channels in HA. Some events or incidents are more appropriately reported direct to line management in the most timely fashion.Supervisors may assess themselves by asking:

“On a scale of 1 – 10, how do I assess myself as a facilitator to my team members in reporting events or incidents?”

For frontline staff“On a scale of 1 – 10, or little vs medium vs much, do I feel at ease in reporting events and incidents to my supervisor?“ “On a scale of 1 – 10, or little vs medium vs much, do I know how to recognize potential negative impact or harm to patients in my daily work?”

HA Risk Alert Editor in-chief: Dr. Tak Yi CHUI, Dep CM(PS&RM), HAHO

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SHARINGDO HOSPITAL INCIDENT REPORTING SYSTEMS CAPTURE MOST PATIENT HARM ?

MEDICATION INCIDENT STATISTICS FROM JANUARY TO JUNE 2012

EDITORIAL BOARDEditor in-chief: Dr. Tak Yi CHUI, Dep CM(PS&RM), HAHO

Board Members: Dr. Clarence LAM, HKWC SD(Q&S) / QMH CONS(HAE); Dr. Y W TSANG, KCC SD(Q&S) / QEH CON(Path); Dr. Petty LEE, P (CPO), HAHO;Mr. Fred CHAN, SM(PS&RM), HAHO; Dr. Venus SIU, 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

No. of Incidents

by Severity

Severity

IndexFrequency

0 156

1 514

2 111

3 16

4 10

5 0

6 0

Top 3 Most Common Error Types

PRESCRIBING DISPENSING ADMINISTRATION

Position In-patient Out-patient In-patient Out-patient In-patient Out-patient

No. 1

Wrong Strength /dosage

(34%)

Wrong Patient (44%)

Wrong Drug (40%)

Wrong Drug (25%)

Dose Omission

(26%)

Others (18%)

No. 2Wrong

Frequency (12%)

Wrong Drug (12%)Wrong

Strength/ dosage (27%)

Wrong Strength/

dosage (20%)

Extra Dose (16%)

Wrong Dose / Dose

Omission / Known Drug Allergy (14%)

No. 3 Wrong Drug (12%)

Known Drug Allergy (11%)

Wrong Label information

(12%)

Wrong Label information

(15%)

Wrong Drug (13%)

Extra Dose (11%)

REFERENCE: Medical Abbreviations: 32,000 Conveniences at the Expense of Communication and Safety, Neil M Davis, 15th Edition

SHARINGTIPS FOR MEDICATION SAFETYIn order to minimize medication incidents due to misuse of medical abbreviations, a HA-wide “Do NOT Use List” was prepared and issued by Medication Safety Committee (MSC), HAHO on July 2010. The list contains a number of abbreviations which can cause potential harmful effects and should be avoided in manual prescribing.

Apart from the above list, there are some abbreviations which could be misinterpreted and thus lead to potential harm.

Abbreviation Potential problem Correct meaning / Solution

Mane Misinterpreted as “tomorrow morning” leading to missed dose In the morning

LE/RE/BE Administration site may be interpreted as “EYE” or “EAR” Write in full name (e.g. Left EAR)

IT May be interpreted as Intrathecal/Intratracheal/intratumoral/Intratympanic

Write in full name

/ (slash mark) May be interpreted as “ONE” when followed by a number Use "and", "with" or "per"

Inadequate spacingbetween drug name and dosage

May make confusion to the actual drug dosage(e.g. Inderal 40 mg misread as Inderal 140 mg)

Always leave a space between a drug name, dose, and unit of measure