Sunday, May 28, 2017

Hospital Error

Have you ever had to investigate any cases of error during your time working in a supervisory role in a hospital? Would you be able to discuss what happened, while preserving the anonymity of all involved? Were any steps taken to make it less likely that such mistakes would happen in the future?




22 comments:

  1. Yes, I had done one adverse event.
    Would you be able to discuss what happened, while preserving the anonymity of all involved?
    That day I was assigned as a screening nurse. A man aged 52 years complaint stomachache. His vital signs were normal, and he was full consciousness. He has no any condition and no underlying disease and no urgent symptom presented. So I invited him to wait a doctor at the waiting zone. Ten minutes later, he had cardiac arrest. The patient was move to the emergency room and cardio- pulmonary resuscitation is immediately needed. Finally, he was safe, and many investigations were started.
    Were any steps taken to make it less likely that such mistakes would happen in the future?
    It was the worse situation in this case. Many diseases tend to be concealed when people access in a hospital. So, the nursing committee and specialists wrote the clinical practice guideline to monitor all of clinical risks which could be occurred. Moreover, the risk management program (RM) was lunched since then. There are three items including risk identification, risk assessment and risk mitigation. I would like to recommend that nurses always keep in mind when the clients come to hospital either OPD or IPD nursing round activity is always done because the unexpected event would happen every time.

    ReplyDelete
    Replies
    1. So glad that this situation was resolved in a satisfactory manner. It is interesting that when suffering from problems with his heart, that patient was experiencing a stomachache. Recently in New Zealand, our public health authorities have been running an advertising campaign to make members of the public aware of the symptoms of an encroaching heart attack.
      David :-)

      Delete

  2. I ever had experience in case nursing student medication error.That situation was happened at Psychiatric hospital .First day of 3-year nursing students are practicing on Psychiatric setting one of my nursing student was getting medicine overdose to one patient (Valium 1tab before bed time.regular dose) ; was unaware that the medication was given 7 tab. and wrong time.Upon further investigation,found student do not have access into paper MAR (Medication administration record).They work directly under the supervision of medication nurse.Physician notified of incident,patient 's vital sign assessed,gastric lavatory.After that,nursing committee and professional school of nursing, they've finding guidance for reduce the risk of student involved errors by implementing key strategies,including incorporation of academic and experiential medication safety content into school curriculum and on site training programs.

    ReplyDelete
    Replies
    1. How about the patient after that?

      Delete
    2. Thanks for sharing this story, Nine. Good to hear that changes were made so that nurses were made more aware of the need to be vigilant when giving out meds.
      david :-)

      Delete
    3. I think medication error is a big problem in many hospitals in Thailand, especially the errors from nursing students. Major causes of problems are lack of awareness and understanding and sometimes the supervisors or staff nurses do not follow the guideline. In my opinion, in all cases where a student is involved with the administration of medicines, the preceptors should double check medical order and must remain with the student throughout the whole process.

      Delete
    4. Actually,The patient still alive.She deep slept all day.After,she woke up her's conditions was better than before.Because of normally in psyciatric patients has a insomnia symptom.They can not sleep well in bed time when they getting enough rest that is good for them.

      Delete
    5. Thanks for your good opinion..Linnapat ^^

      Delete
    6. Really? She was better than being taken a normal medicine, so why don not experts give more medicine as a criteria

      Delete
  3. Have you ever had to investigate any cases of error during your time working in a supervisory role in a hospital? Would you be able to discuss what happened, while preserving the anonymity of all involved?
    I ever had experience with error detection . About 2 mouths ago my uncle has stomachache very much so we took him to the hospital .The doctor (extern,who is the study physician in the last year) investigate him by lab and examination and diagnosed is cystitis and gastroesophageal reflux disease ( GERD). I very confuse why the doctor don’t diagnosed appendix or appendicitis because usually of cystitis is rare case in the male .I asked Doctor for make sure but he confirm the answer is correct. After that about 7 hour my uncle had stomachache again and more than the first time , so we comeback to the hospital again and I met other Doctor ,he investigested by examination founded McBurney's point response and CT whole abdomen that founded appendicitis . So the Doctor set operation for appendectomy worse than that the appendic was rupture enable to Doctor operation for appendectomy and exploratory. The worse situation affect to my uncle very much. He stayed in the hospital long time and painful so much.

    Were any steps taken to make it less likely that such mistakes would happen in the future?
    1.Base on ability of Physician for investigate the disease by symptoms , examination ,Laboratory and technology’s medicine are appropriate with disease or disorder.
    2.use consult system for early detected follow the CPG or CNPG.
    3.Continious follow the symptom’ patients is improve or not. If the symptom is worse should review treatment and conference with care team for treat.

    ReplyDelete
    Replies
    1. Thanks for sharing this case, Ploy. So sorry that your uncle had to go through this. It must have been difficult for you to experience this case of misdiagnosis from the point of view of a family member of the patient's.
      David

      Delete
    2. thank you teacher. Even if hospital error is trouble,this point is always optimistic.Because we learned about the way to decrease mistakes in the future.

      Delete
  4. I have experienced to examine the medication administration error of my student, she is the 4th years nursing student. While she was practicing in out-patient unit with nursing staffs, an old man with chronic lower back pain came to the hospital. He had severe back pain and came to get analgesic, intramuscular injection of Diclofenac at the out-patient unit. He received Diclofenac injection several times before and had no side effects. My student was assigned to give him an injection by the nursing stuff. The student followed the “6-rights” of medication administration (right patient, right drug, right time, right route, right dose and right record), but she gave an injection for a patient without supervision because the staffs were busy with another patients and she did this procedure many times before so the staffs trust her. After she gave an injection to a patient, he couldn’t lift his right leg but still could move, he had muscle weakness.

    The doctor said, it’s a result from compression of the sciatic nerve (it’s a major nerve of lower limb and connect the spinal cord with the leg and foot muscles.), it might be because my student’s injection was too low and it caused nerve compression, but it’s still lucky that it didn’t hit the sciatic nerve, otherwise a patient would get leg paralysis. After that, the patient had physical therapy about 3 months and he can walk as usual again.

    After an incident, we emphasized the preceptors and nursing staffs to follow the clinical supervision guidelines that we gave them before start practicing. For example, the student nurses must never administer medication without supervision, and in all cases where a student is involved with the administration of medicines, the preceptors must remain with the student throughout the whole process.

    ReplyDelete
    Replies
    1. Thanks for sharing this story, Lin. You described what happened lucidly. Clearly giving injections is a challenging task at times, especially when the results of making a mistake can be as severe as paralysis. Good to read that clinical supervision guidelines were in place to help minimise the risk of mistakes being made when giving injections.

      Delete
  5. Actually, I am a public health officer who works as emergency administration at public health provincial office. So, I never investigated the error in a hospital. However, I have participated in the committee called the inquest for helping the victim who suffered from provider's health services. This inquest focuses on investigating the case errors which are caused by health provider's mistakes occurred to patients as well as compensating some fund for them.

    The biggest error that I have found was the doctor operating patient' leg incorrectly. This error had been occurred by the doctor; at first the doctor had interpreted a scanning result and found that there was patient's right leg injured ligament. Thus, the patient had to be operated. Before the operation would be happened, nurses had prepared the patient with lying down with turning face up. When everything was ready, the doctor had interpreted the scanning result for sure again aside right hand side of the patient and changed the patient's position to lie prone because it was easier than to continue the process. Nevertheless, although the patient had changed the position to another side, the doctor still stood at the same side. Thus, he had operated patient's left leg. This error had made the patient be so dissatisfied. Eventually, the doctor was accused by this victim.

    After the committee investigated the error, found that it resulted of careless behavior of the doctor. So, the committee had commanded this doctor to write the long report to review the mistake, discover the effective solution and determine the efficient risk management.

    ReplyDelete
    Replies
    1. An interesting story, Mint. You'd have to say that cases of the wrong limb being operated upon are some of the more disturbing and tragic cases of medical mistakes. Was the patient compensated?
      David

      Delete
    2. He was compensated with some money from the National Health Security Office (NHSO, which is responsible for compensating some budget to the patient who suffer in health workers' mistakes. This organization often compensate some budgets after the verdict of the inquest for helping the victim who suffered from provider's health services committee.

      Delete
  6. I have investigated drugs error of a baby who was injected by a nursing student, when I worked as a nursing instructor in second year. During that time, I attended a senior nursing instructor, she taught nursing students who practiced at labor room. At labor room, after babies born, nurse must injected vitamin K1 1 mg to babies for helping their body from present with bleeding. Phamacist send vitamin K for strock at labor room and nurses keep it at the shelf. Nursing student could do anything under the supervision of register nurses.
    One day, one of nursing student injected vitamin K1 into a baby and tranfered baby to post partum ward for caring baby. Afterward, another baby born, nurse also injected vitamin K1 to baby. Suddenly, she found vitamin K1 in strock was vitamin K1 10 mg, it cannot to injected to babies. So that she count vitamin K1 in strock, it was use 1 ampule. All nurses helped to find which baby was injected by vitamin K1 10 mg, and they found it was use with baby who was injected by nursing student.
    After that, leader nurse of labor room coordinated with doctor and nurses at post partum ward. They took care that baby closely for watching complications that can occur hemolysis in newborn by vitamin K1 toxicity. Fortunately, the baby had no sign and symptom of that complications.
    As mention above, all involved I, senior nursing instructor, doctors, nurses and nursing student. We talked together too much in order to find method for preventing solutions in the future. From this situation anyone involved lacked of providence to checked accuracy. Vitamin K1 were misrepresent by pharmacist, were not check before keeping in shelf by nurses and were not check again before injecting by nursing student.
    Nevertheless, we could handle with this problem and added a significant increase monitoring of medications all area in hospital.

    ReplyDelete
    Replies
    1. Thanks for sharing this story, Sai. The message of the need for regular checks re. medication comes across loud and clear. It is easy to see how mistakes can creep in especially where routine injections are involved. As staff have given them without incident so many times before, the temptation is to stop being vigilant.
      David

      Delete
    2. Of course, this incident case happened by careless from staff nurse to student nurse and happened by lack of prudence to rechecked by pharmacist before dispensation and staff nurse before medicines storage. So that everyone involved should be more careful and do the best ways on their job descriptions.

      Delete
  7. The error or the mistake was found a little that it was about the documents which were communicated and coordinated with another sections, it caused the response from another sections was late. Sometimes, lack of equipments and the skillful staff for measure of sampling in evironmental health affected to error of solve the problem in environmental health such as wastewater, air pollution and nuisance. Although, work was more attention and more carefully resulted that the errors were lower. Moreover, improving the skills of environmental health for staff who was concern, were necessary because the job was more efficient and more successful, and it was a part or factor to consider of the options for solving of the ploblem and management of the risks that affected to health.

    ReplyDelete
    Replies
    1. Thanks for sharing your experience, Nuit. Clearly systems have to be in place to ensure timely communication between individuals and sections within the same organisation. The trick is introducing the appropriate amount of paperwork etc. Too much, and the response to crises will be slowed rather than enhanced.
      David :-)

      Delete