Incident Report

CLINICAL INCIDENT REPORTQMD-03-004-00Page 4 of 4

STRICTLY CONFIDENTIAL UNAUTHORIZED REPRODUCTION OF THIS DOCUMENT IS STRICTLY PROHIBITED

REPORTING PARTY REQUESTED CONFIDENTIALITY? FORMCHECKBOX YES FORMCHECKBOX NO

INCIDENT NOTIFICATION (to be completed by Department Quality Circle/investigating body)

SUBJECT DETAILS

LAST NAME SzeFIRST NAME

Yeung Ping

RECORD/PATIENT NO:181900UNIT5 MAIN

DATE OF BIRTH 12.13.40AGE83SEX

Male

FORMCHECKBOX PATIENT FORMCHECKBOX VISITOR FORMCHECKBOX EMPLOYEE FORMCHECKBOX OTHER:

PLACE OF INCIDENT (Where did the incident occur?)

UNIT E.G. RADIOLOGY DEPT./6TH FLOOR

SPECIFIC LOCATION E.G. BATHROOM, X-RAY ROOM

DATE OF INCIDENT (MM/DD/YR): August 8,2013TIME OF INCIDENT:3:00PM

DEPARTMENT OF SPECIALTYMedicine

INCIDENT INVESTIGATION AND ANALYSIS (to be completed by Department Quality Circle/investigating body)

DESCRIBE THE ACTUAL OR POTENTIAL INCIDENT:

Please include the immediate response and outcome. For medication incidents please state all drugs involved. (Please attach an extra sheet of paper if needed).

That on August 7,2013 at around 10:20PM Dr. Peter Sy ordered Peptamen 5 scoops in 180 cc water every 4 hours as drip for patient 507 Sze Yeung Ping.

The bedside nurse on that shift (CB shift 6PM-6AM) Benedict Mecija was the one who started and prepared the Peptamen fomula.Nurse Benedict fixed the Peptamen formula at 4AM, Nurse Benedict rinsed the calibrated glass and spoon using the patient's own bottled water but the relative made another cleaning of the glass & spoon using warm water, Nurse Benedict & the relative cleaned the surface where the peptamen will be prepared, with mask & gloves on during the entire preparation. Nurse Benedict opened the new can of Peptamen and mixed it with 180 ml of bottled water.He also checked for the patency of the Kangaroo bag and its tubing before he put the Peptamen Formula in the Kangaroo bag then he primed the milk and connect it to the gastrostomy tube. Nurse Benedict stay for the patient for 15 minutes for regulation and observation of the feeding.

That on August 8,2013 CA shift (6AM-6PM) nurse Emmanuel Colipano was the assigned bedside nurse to the patient.At 7:30AM Emman was due to prepare his Peptamen Feeding.But before doing that Emman assess the gastrostomy tube of the patient.Then Emman started to prepare the Pepatmen Formula, the patient's wife was the one who washed the calibrated glass used for mixing the Peptamen Formula, with mask & gloves on nurse Emman combine the water & Peptamen and he make a thorough assessment on the kangaroo bag , cheked for any leak and he saw nothing except for the lumps of undiluted milk powder from previous feeding, the patient's wife was beside nurse Emman all through out the preparation of the Pepatmen Formula and until he poured it to the Kangaroo Bag.Then at around past 1PM the relative noticed a dot black particle on the bag of Peptamen Formula then nurse Emman informed me.

CONTRIBUTING FACTORS

Please include any factors contributing to the incident including: Staff factors e.g. fatigue, skill/knowledge deficit, failure to follow policy, communication problem. Subject factors e.g. mental condition, social support, aggression, inadequately medicated, over stimulated environment, failure to follow instructions. System factors e.g. access to services, lack of training/policy/facilities. Consider anything that occurred immediately before the incident.- water

- Peptamen Formula

- Kangraroo bag

- nurse who prepare the Peptamen

TREATMENT/INVESTIGATIONS ORDERED

E.g. X-ray, Blood test, ECG, EEG, Dressings, New medications, Referral for review by another clinician.

WHAT FACTORS MINIMIZED THE OUTCOME?HOW COULD THE INCIDENT HAVE BEEN PREVENTED?

E.g. early detection by monitor or alarm. Good assistance, Good plan or protocol, Consultation or conciliation, do-escalation techniques, use of PRN medication.

E.g. Equipment checks before use, better written or verbal communication, and better work lay-out/teamwork.The kangaroo bag should be change every feeding of the patient.

Name: Date: / / Time:

INCIDENT INVESTIGATION AND ANALYSIS

SENIOR STAFF EVALUATION

To allow for full evaluation of the incident, please ensure that all results are available e.g. blood test, X-rays etc.

Describe results of investigation and findings. Please do not repeat a description of the incident

The small black dot that the relative noticed and claimed as " insect " was immediately coordinated with the warehouse supervisor Ms. Anna beacuase I doubt that it was an insect and best described as carbon paper, but if you were going to closely check and feel it, it can be best described as like rubber thing.

The kangaroo bag with the small black dot together with the milk from the bag was sent to warehouse for investigation care of the supplier. Ms. Anna coordinated with the supplier.

That on Monday August 12,2013 at around 9AM the milk was sent to laboratory for culture to check for any bacteria that contaminated the Peptamen Formula.

That on Wednesday August 14,2013 around 2PM the result of milk culture was released as ACINETOBACTER BAUMANII - VERY LIGHT GROWTH.I inquired to the senior MedTech Ms. Maria Criselda Del Rosario about the bacteria and where it came from, she told me that ACENITOBACTER BAUMANII possibly came from environment & handling of the milk. I informed Dr Peter Sy about it.

That on Thursday August 15,2013 Dr Peter Sy told me that he informed the patient's wife about the very light growth of bacteria found in the milk culture. To further explore the ANICETOBACTER BAUMANII, I asked the Infection Control Ms. Rhoda Gayco about the said bacteria and she told me that possible sources of it were the water,the kangaroo bag, milk (peptamen formula) and the nurse who prepares it. ANICETOBACTER BAUMANII is a water organism and isolated from hospital environment & hospitalized patient. My analysis about the ANICETOBACTER BAUMANII found in the milk culture could be from the water since the bacteria is a water organism.

Name: Alona D. Alfaro,RN Signature:

Designation: Charge NurseDate &Time: August 15,2013

THIRD PARTY COMMENTS

Please forward this form to any relevant 3rd party area for comments e.g. Pharmacy, Radiology, Laboratory, etc.

Name: Signature:

Designation: Date &Time:

DEPARTMENT/SERVICE HEAD OR DIRECTOR COMMENTS

Comment on action taken or needed to prevent recurrence. Comment on resource implications. Please do not repeat the senior staff evaluation.

Did the incident result in an increase of costs or length of stay, or consume extra resources? Please specify:

No it did not increase any costs to the patient. The patient was discharged on December 2, 2012

Name: Ms. Delia C. Ramos, CCRN, MAN Signature:

Designation: Nursing Division Head Date &Time:

DO NOT PUT THIS FORM INTO MEDICAL RECORD