ISSUE 15 MAR 2010

A Risk Management Newsletter for Hospital Authority Healthcare Professionals

In the Hong Kong West Cluster (HKWC), we have developed a method to investigate and reduce risk known as “System Evaluation of Reported Adverse Events” or its acronym SERAE. I am sure we are all familiar with “Root Cause Analysis” (RCA) which is the investigative method for a sentinel event that has already occurred. There is also an analysis method to identify potential adverse events that has yet to occur which is known as “Failure Mode and Effects Analysis” (FMEA). This latter method, however, is rather laborious and is often criticized as being too theoretical for the discussion surrounding events that have not been detected yet. In HKWC, the SERAE method is for events that have occurred but not in one’s own institution. It is no longer theoretical because the event is already identified in the other institutions but it must be such that operational details on the incident can be obtained. This is why “Risk Alert” is so useful because it will often describe actual adverse events with illustrative flow charts providing pertinent details. Information on adverse events that occurred in other hospitals/centers can raise a “red flag” to all and is only one aspect of reducing risk. The facts and data of adverse events must be systematically utilized to analyze the systems in one’s own institution and to formulate new or redesign existing procedures to reduce the risk. This is the purpose of SERAE so that in the end reasonable recommendations and applications for improvement can be derived. It is how Risk Alert is utilized in our cluster and the results are extremely positive. However it is not the only benefit. The sharing and learning help us to realize that we are not alone but the work of risk management is organization wide. Indeed, we must work together to make our hospital safe for our patients and for all concern.

Dr. W H SETO, CD (Q&RM), HKWC

A Cluster Chief Director of Quality and Risk Management’s perspective on Risk Alert

§ Local risk scanning

Handling of Oxygen regulator

Safe use of Midazolam injection

§ Risk reduction program

Safe handling of specimen bottle

Surgical safety checklist

§ Local sentinel event

Distribution of sentinel events

Retained intravascular guide wire

Retained a raytec gauze in vagina

after normal delivery

Retained a fragment of urinary catheter

1

1

1

12

5

3

13

1

5

2

2

11

7

5

4

6

5

0 5 10 15 20 25 30 35 40 45

Unexpected death or serious disabilityreasonably believed to be preventable

Infant discharged to wrong family or infantabduction

Maternal death or serious morbidityassociated with labour or delivery

Death of inpatient from suicide (includingsuicide committed during home leave)

Intravascular gas embolism resulting indeath or neurological damage

Medication error resulting in majorpermanent loss of function or death

Haemolytic blood transfusion reactionresulting from blood group incompatibility

Retained instruments / material aftersurgery / interventional procedure

Surgery / interventional procedure involvingthe wrong patient or body part

Oct 07 to Mar 08Apr 08 to Sep 08Oct 08 to Mar 09Apr 09 to Sep 09

Link to information on SERAE: http://www.ha.org.hk/visitor/ha_view_content.asp?content_id=200682&language=ENG

RETAINED INTRAVASCULAR GUIDE WIRE

Held by handClamped by forceps Fixed by tegadem

A junior doctor performed the procedure to insert a central venous

catheter.He experienced difficulty with the

insertion of the guide wire and was assisted by his supervisor.

After the insertion, there was difficulty to flush the lumen of the

catheter.

After the guide wire was inserted, the junior doctor inserted the catheter

by threading it over the guide wire. A Post-procedure

Chest X-ray revealed a

guide wire in the inferior

vena cava.

The guide wire was retrieved via endovascular

approach.

RETAINED A RAYTEC GAUZE IN VAGINA AFTER NORMAL DELIVERY

NO

postoperatively.

slipped out.

admitted to another hospital.

Cystoscopy was performed during which a fragment urinary catheter was removed.

Key contributing factor: Confused patient with violent behaviour.

1. To alert staff on the rare possibility of shearing off of balloon fragments

of urinary catheter.

2. To check the integrity of urinary catheter, particularly in slip-out cases and

patients with confusion.

To develop a robust process to help doctors to keep track of the tail-end of the guide wire throughout the whole insertion procedure, especially during the threading of the catheter over the guide wire.

Key contributing factors:

inadvertent retention of guide wire.

Ineffective communication between team members.

1. To adopt a robust process to keep track of the tail-end of the guide

wire throughout the procedure.

2. To count and verify the guide wire immediately after insertion of the

central venous catheter and removal of the guide wire from the patient.

3. To provide appropriate training and supervision for junior staff on

insertion of central venous catheter.

Key contributing factors:

1. To establish an accurate counting process both at the start and end of delivery.

2. To standardize the documentation of counting (worksheet / whiteboard).

RETAINED A FRAGMENT OF URINARY CATHETER

The National Patient Safety Agency (NPSA), UK received 281 reports of incidents related to inappropriate administration and management of oxygen between December 2004 and June 2009. Incidents related to improper use of oxygen regulator have also occurred locally.

What has happened?

Out-Patient Clinic. The patient was to receive oxygen therapy via nasal cannula during transfer process.

pointer was in the green zone (ON).

(the meter pointer was in the green zone reflected there was oxygen).

Possible causes:1. Staff factor: Non-compliance with the practice of the oxygen cylinder operation.2. Management factor: Inadequate training for the supporting staff on operating oxygen cylinder.

transfer.4. Equipment factor: No standard “open/close” indicators on oxygen cylinder.

Improvement actions:1. To promote good practice of oxygen administration to all clinical staff.

transfer.3. To liaise with Hong Kong Oxygen Company for improvement on the “open/close” indicator for all oxygen cylinders.

HANDLING OF OXYGEN REGULATOR

The pointer in the green zone may only indicate there is oxygen in the meter gauge but not necessary active oxygen flow. There is need to ensure that the cylinder valve is turned “ON” and there is actual oxygen flow from the outlet of cylinder to patient.

open / close indicator

mpanymp

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llll Oong ong

en cyln cy2OO

oing oxatin

of the suup g staf

Oyg

2

OWhWh2haha

Orel

ne2eded O2

OORR22

O2OO

2

SAFE USE OF MIDAZOLAM INJECTION

N

NN

NCl

F

Key messages from the NSW notice

The situation in HA

NCl

F

Case 1:

Learning point: Always counter - check the strength and calculation with anotherstaff before administration

Recommendations from the Safety Solutions on Narcotics/ Opioids 2

Case 2:Case 2:

Learning point: Always prescribe in “mg”, not in “ml”

I l C2mg 2ml

WHAT HAS HAPPENED?A patient mistakenly ingested the Boric acid powder inside the MSU specimen collection bottle which was left at the bedside table for collection of the patient’s urine.

SAFE HANDLING OF SPECIMEN BOTTLE

Case 3:

A patient required debridement of LEFT ankle ulcer and the operation site was marked by Doctor A. The RIGHT ankle was written in the consent form and entered in the operation list by Doctor B.Theatre reception nurse found the discrepancy. The chief surgeon confirmed the LEFT ankle was to be operated on and consent form was corrected after explanation to patient.

Case 1:

Patient was planned to have wedge resection of LEFT lung and operation was marked with CT guidance on the LEFT side.Nurse found that RIGHT side of lung was documented in consent form and operation list. Patient reiterated that LEFT lung was to be operated on. This was subsequently confirmed correct by the chief surgeon.

Case 2:

An orthopaedic patient was transferred to operation theatre. Operation theatre nurse found the name of patient on label of the consent form was different. A new informed consent was signed for the patient in theatre before induction.

EDITORIAL BOARDEditors-in-chief: Dr. SF LUI, Consultant(Q&RM), HAHO; Dr. Libby LEE, CM(PS&RM), HAHO.

Board Members: Dr. W C LAO, HKEC CSD(Q&RM) / PYNMED Cons; Dr. Petty Lee, P (CPO), HAHO; Ms. Bonnie WONG, CM(Q&RM), NTWC; Mr. Fred CHAN, SM(PS&RM), HAHO;

Ms. Katherine PANG, M(PS&RM), HAHO.Suggestions or feedback are most welcome.

Please email us through HA intranet at address:HO Patient Safety and Risk Management Department

Surgical Safety Policy has been implemented since 1 June 2009. The checklist has helped clinical staff to identify errors in patient identification and operation site/side.

SURGICAL SAFETY CHECKLIST

Best Risk Reduction ProgramAfter receiving order from doctor, ward staff will clip a reminder card on the patient’s chart board. Patients will then be instructed to bring the card and ask for specimen bottle when he/she is ready for collection of urine specimen.

WHAT HAVE BEEN DONE?Through Kaizen Suggestion Competition, TMH has adopted a good risk reduction process: to “put a reminder card instead of MSU collection bottle on the patient’s bedside table”. This would eliminate the risk of inadvertent ingestion of non-drug chemical by patient.