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