Critical Incidents Reported to Manitoba Health

Transcription

1 Critical Incidents Reported to Manitoba Health January 1, March 31, 2013 Degree of Minor Minor Resident did not correctly apply brakes to walker. Newly acquired surgical table was missing lateral brace assembly. Not purchased as it was sold as a separate accessory. As a result, patient required repositioning several times during surgery. Following surgical reduction of femur, right foot noted to be internally rotated. Home care worker attempted to enter client's home three times without success. Client refused to have a locked box for key to home. Client noted to not be at home for services on a number of previous occasions. Primary contact not notified. Client found on floor 2 days later. To Emergency Department (ED) where diagnosed with rhabdomylosis. PCH resident who was perceived to be "bossy" pushed by another resident who was difficult to redirect. Fractured hip. Interventions were in place to deal with the conflict between them. Child and mother sitting in outpatient waiting room. Outpatient, known to be Hepatitis C positive, had violent outburst and scratched child breaking skin. Child tested negative for Hepatitis and HIV. PCH resident's wound deteriorated to Stage 3 pressure ulcer. Wound Care Specialist consulted. PCH resident with poor vision had unwitnessed fall resulting in fractured hip. Delay in transfer of unstable patient with acute myocardial infarction from northern community. Lifeflight was not contacted for transfer. While awaiting transport, patient had cardiac arrest. Died. PCH resident's pressure ulcer to coccyx ulcer deteriorated to Stage 3 pressure ulcer following two day hospitalization. Wound care protocols not followed. Mismatched hip prosthesis implanted during total hip arthroplasty. Surgeon trials various plastic parts before desired size and fit determined. No verbal confirmation of correct implant made by involved staff. Additional surgery required to replace prosthesis. Home support worker provided client living with moderate dementia with her husband's medications. Client took these. Adverse reaction resulted resulting in ED treatment. Patient involved in a pedestrian vehicle crash. Fractured arm & pelvis. Discharged home the same day. Not placed on blood thinners to prevent venous thromboembolism. Re-admitted to hospital and later died. Pulmonary embolism found on autopsy. PCH resident had unwitnessed fall resulting in fractured femur. Chair alarm sounded when resident attempted to get up from wheelchair. PCH resident sustained second degree burn to thigh after spilling hot tea on himself. PCH resident who was walking in hallway tripped on oxygen tubing and fell. Fractured hip. PCH resident had unwitnessed fall resulting in fractured hip. High risk for falls. Falls prevention plan not clearly documented. Infant was fed 2 mls of wrong breast milk. No apparent injury. Procedure to verify correct breast milk not followed. PCH resident diagnosed with unstageable pressure ulcer. Deteriorated from Stage 3 pressure ulcer in 4 days. Significant deterioration in general condition. Improperly fitting footwear was a contributing factor. Patient arrived via Emergency Medical Services (EMS) to ED. Eligible for stroke protocol but staff unaware. Opportunity for treatment missed. Patient's pressure ulcer deteriorated from Stage 2 to unstageable during one month hospitalization. Existing protocols did not address patient s significant risk factors. Delay in recognizing positive blood culture delayed treatment of infant with meningitis. Four days following PICU admission, treatment withdrawn. Infant died. PCH resident was found by night staff half way out of bed with head on mattress and feet on floor. Bed side rails were in use. Deceased. Page 1 of 6

2 PCH resident had unwitnessed fall in her room resulting in fractured hip. Died 2 days after hospital admission. Not known if surgery completed. PCH resident had unwitnessed fall resulting in fractured hip. When attempting to sit down, resident missed wheelchair seat. Patient developed unstageable pressure ulcer to coccyx and buttocks. Preventive interventions were in place prior to its development. PCH resident's Stage 2 pressure ulcer on buttock deteriorated to Stage 3 in spite of intervention. General deterioration in health status noted concurrently. Patient developed unstageable pressure ulcer to coccyx. PCH resident living with cognitive impairment who desired their independence had unwitnessed fall resulting in fractured hip. PCH resident had unwitnessed fall resulting in fractured hip. Family declined surgical intervention. Died five days following surgery at PCH. PCH resident had unwitnessed fall from their bed resulting in fractured hip. PCH resident developed unstageable pressure ulcer to coccyx. Not willing to be repositioned on turning schedule recommended as part of treatment plan. Patient developed unstageable pressure ulcer to heel. Risk assessment and prevention/treatment plan not well documented. Patient had allergic reaction during surgery. Code Blue called. Thyroid artery was nicked when a cricothyrotomy was performed. Admitted to ICU. Discharged home 3 weeks later. PCH resident developed Stage 3 pressure ulcer despite prevention plans and interventions. Patient's wound deteriorated to Stage 3 pressure ulcer upon transfer five days earlier. Decreased mobility following hip surgery. Misjudged position of her walker when she went to sit down on it. Immobile PCH resident developed two unstageable pressure ulcers on heel and coccyx. PCH resident who required turning and positioning developed Stage 3 pressure ulcer to heel. Recent deterioration in general health status. Not compliant with turning and positioning schedule. PCH resident had unwitnessed fall resulting in fractured hip. Decision to manage fracture without surgery. PCH resident had surgery for repair of fractured hip. On return to PCH, blisters noted to heel. Later deteriorated to Stage 3 pressure ulcer. Following treatment, dialysis patient tripped and fell sustaining facial fractures. Felt weak and dizzy prior to treatment but refused assistance. Condition deteriorated. Admitted to ICU with aspiration pneumonia. Recovered. PCH resident living with dementia and wandering behaviour had unwitnessed fall resulting in fractured elbow. Patient on pressure support ventilation. Tubing at bottom of ventilator became disconnected. Code Blue called. No resuscitation performed in keeping with advanced care plan. Patient developed unstageable pressure ulcer to sacrum during hospitalization. Ongoing wound care prior to hospital admission. General deterioration in health condition. Bilateral mastectomies & breast reconstruction procedure. Pressure inadvertently applied to popliteal nerve resulting in compartment syndrome. Emergency fasciotomy of leg required. Patient exited facility undetected through unlocked door. Returned to the unit via wheelchair. Treated for hypothermia and frostbite to both feet. Patient who was confused fell fracturing their femur. Later had a cardiac arrest while in Dialysis Unit. To ICU where later died. PCH resident, who valued their independence, had unwitnessed fall resulting in fractured hip.

3 Patient at high risk for falls fell from bed to the floor. Fractured femur. Patient had unwitnessed fall. Cardiac arrest with successful resuscitation. CT scan of head showed massive intracranial bleed. Family decided to provide comfort care. Died. Patient with constant care attendant fell hitting the back of head against shower wall. Died two days later. PCH resident who ambulated independently had unwitnessed fall resulting in fractured hip and wrist. Surgical repair of hip completed. Patient developed Stage 3 pressure ulcer to coccyx following hip surgery. Admitted to hospital with the beginning of a coccyx pressure ulcer present. Patient had CT scan and MRI 7 months earlier which showed metastatic pancreatic cancer. No treatment plan was put into place until they presented ill to the ED. Referral to Oncology clinic not prioritized. PCH resident had unwitnessed fall from bed to fall mat on floor. Fractured femur. PCH resident sustained second and third degree burns to their foot. Because of room size limitations and the need to use a mechanical lift, their bed was positioned close to the baseboard heater. Resident slept with their feet dangling off the bed. Due to disease process, resident had decreased sensation to their feet. Plastic surgery consulted for treatment plan. PCH resident had unwitnessed fall. Heard calling out and found lying on back. Fractured hip. Patient treated for hypernatremic dehydration in ED. Subsequent seizure and cardiac arrest. Successful resuscitation. Later died in ICU. Patient underwent surgery to resect bowel due to obstruction. During surgery, foreign material was found in the bowel. Patient had previous bowel resection in PCH resident received high dose of Lithium due to a calculation error printed on the medication label. Admitted to ICU for dialysis. Patient developed unstageable pressure ulcer to buttocks during hospitalization. Felt to be developing this prior to admission. Medical condition deteriorating prior to hospital admission. During 7 week hospitalization, patient with cognitive impairment developed unstageable pressure ulcer to heel despite appropriate preventive interventions. Non-compliant with positioning schedule. Home care client with quadriplegia spends much of day up in wheelchair with pressure reducing cushion. Stage 2 pressure ulcers deteriorated to unstageable. Patient with coronary stents to Kidney Health Clinic coughing up blood. Blood thinners discontinued. Discharged from hospital. Later suffered myocardial infarction. Died in ICU. Mental health inpatient, suicidal with alcohol addiction, ingested hand sanitizer. Toxic ETOH levels and ICU admission. Recovered. Patient, confused and at high risk for falls, got out of bed and fell. Head injury and fractured hip. Home care client of Family Managed Care Program. High risk for development of skin breakdown. Family not wanting to "medicalize" home with equipment. Developed unstageable pressure ulcer. PCH resident had unwitnessed fall resulting in fractured hip. Determined not to be an appropriate candidate for surgery. Patient admitted to hospital due to increasing care needs in the community. Despite appropriate interventions, developed unstageable pressure ulcer to sacrum. PCH resident's pressure ulcer deteriorated to unstageable pressure ulcer despite appropriate care over the past year. PCH resident developed Stage 3 pressure ulcer to hip. General condition had been deteriorating for several months. Non-compliant with treatment plan. Patient at high risk for skin breakdown developed unstageable pressure ulcer to heel. PCH resident at high risk for skin breakdown experienced deterioration of pressure ulcers to both heels two weeks after admission to PCH. General state of health poor and deteriorating. PCH resident who was transferred to hospital was returned to PCH. Two weeks later found to have developed unstageable pressure ulcer to coccyx. Patient's leg buckled while walking. Fell to floor. Fractured femur. Had been preparing for discharge home prior to fall.

4 Patient developed unstageable pressure ulcer to sacral area despite treatment. High risk for skin breakdown due to diagnosis of cancer. Patient receiving palliative care developed Stage 3 pressure ulcer to heel during hospitalization. Patient transferred to ED following previous motor vehicle crash. Missed diagnosis of fractured ribs and ruptured spleen. Subsequently admitted to ICU. Home care client, at high risk for skin breakdown, found to have developed an unstageable ulcer to foot by wound care specialist. Poor circulation was a contributing factor. PCH resident had witnessed fall. No injury noted initially. Two weeks later, found to have fractured hip requiring surgical repair. PCH resident had unwitnessed fall. Found lying on their back in hallway. Resident reported hitting back of their head. Fractured hip. PCH resident had unwitnessed fall resulting in fractured hip. Found on floor by bed. Surgical repair completed. PCH resident found in respiratory distress. Condition deteriorated despite administration of oxygen. Cardiac arrest. Advanced Care Plan Level indicated desire for comfort care. Died. Patient presented to the ED. Failure to recognize early signs of renal failure resulted in ICU admission and sepsis. Critically ill patient developed an unstageable pressure ulcer to the coccyx. PCH resident had unwitnessed fall resulting in fractured femur. Tripped over urinary catheter drainage bag attached to bed frame. PCH resident fell after trying to stand up. Fractured pelvis. Conservative non-surgical treatment. Home care client received spouse s medications in error. Medications were blister packaged. Treated with activated charcoal in the ED. PCH resident had limited mobility following repair of fractured hip. General condition deteriorating. Developed Stage 4 pressure ulcer to coccyx. PCH resident with pre-existing auto-immune disorder developed Stage 3 pressure ulcer to coccyx. PCH resident living with dementia had unwitnessed fall resulting in fractured hip. PCH resident found to have developed pressure ulcer at time of admission to hospital. PCH resident with fractured wrist developed ulcers to left wrist and arm from incorrectly wrapped tensors. Patient receiving radiation therapy developed unstageable pressure ulcer on coccyx. Later thought that this was related to radiation therapy. Home care client discharged from hospital with Stage 2 pressure ulcer on coccyx. Deteriorated to Stage 3. Seating assessment not able to be completed prior to discharge from hospital. PCH resident with poor vision had unwitnessed fall resulting in fractured hip and wrist. Surgical repair completed. Home care client, at high risk for skin breakdown, developed Stage 3 pressure ulcer to hip despite appropriate prevention plans. PCH resident had witnessed fall and struck head. Unresponsive. To ED where intracranial bleed found. Palliative care provided as per family wishes. When slab cast removed, patient who was at high risk for skin breakdown, found to have developed unstageable pressure ulcer to heel. Patient underwent by-pass surgery. Medications to reverse paralysis given in wrong order. Cardiac arrest. PCH resident developed Stage 4 pressure ulcer to coccyx. Patient, at high risk for skin breakdown, admitted with a small open area on coccyx. Once debrided, Stage 4 pressure ulcer discovered. PCH resident developed Stage 3 pressure ulcer. General condition deteriorating recently. Poor nutritional status.

5 Patient returned from another hospital with an extravasation injury to hand at previous intravenous insertion site. Plastic surgery consulted. Patient referred from another site for bronchoscopy. On arrival, no palpable blood pressure. Procedure began. Suffered cardiac arrest. Died. PCH resident had unwitnessed fall during the night resulting in fractured hip. Found lying on the floor crying. PCH resident had unwitnessed fall during the night. Heard calling out for help and found on floor. Fractured hip. Mental health patient was throwing punches at staff. During attempts to restrain, patient fell onto one of the staff members. Later discovered that the patient had broken his arm. Two day delay in reviewing critically high laboratory test resulted in delay in treatment for pulmonary embolism and extended hospitalization. PCH resident had unwitnessed fall during the night. Found on the floor, moaning. Fractured hip. PCH resident developed Stage 3 pressure ulcer to their hip despite several preventive interventions. Patient presented to the ED with abdominal pain. Discharged the following day. Two days later, returned to ED. Perforated appendix. Emergency surgery and ICU admission required. PCH resident had unwitnessed fall during the night. Found on the floor next to bed. Fractured hip. Patient had unwitnessed fall in room resulting in fractured hip. Patient with acquired brain injury wanting to go to the bathroom. Staff requested that she wait as floor recently mopped & wet. Patient refused to do so. Fell sustaining fractured femur. During surgery, air was inadvertently pumped into the patient's carotid arteries due to equipment issues. Sustained multiple strokes. Died. PCH resident had witnessed fall while trying to grasp wall for support. Fractured hip. Surgical repair completed. PCH resident had unwitnessed fall. Found lying on floor near elevator entrance. Fractured hip. Patient received unnecessary cycle of chemotherapy based on initial diagnosis of high grade malignancy. Subsequent diagnosis of low grade malignancy was made that did not require chemotherapy. PCH resident's pressure ulcer deteriorated from Stage 2 to unstageable during hospitalization. Very limited mobility. PCH resident, at high risk for falls, had unwitnessed fall. Found on bathroom floor calling for help. Fractured hip. Died a few days later. Immobile patient diagnosed with Stage 3 pressure ulcer. No prevention plan was found to be in place. PCH resident stood up using their wheeled walker for support. Fell backwards onto the floor hitting their head. Intracranial bleed. Died two days later. PCH resident sitting in wheelchair reached for an object and fell. Dislocated shoulder. Surgical repair completed. PCH resident had unwitnessed fall resulting in fractured hip while walking back from bathroom. PCH resident was pushed by co-resident. Fell and fractured humerus. Patient developed unstageable pressure ulcer to coccyx. Limited mobility, poor nutritional status and previous history of pressure ulcers. Patient having surgical rectal anastomosis. When skin stapler used, tear in anastomosis resulted. Additional surgery time, creation of an ostomy for diversion and future surgery for reversal required. PCH resident with cognitive impairment had unwitnessed fall. Found on floor beside bed. Fractured femur. Determined that resident was not a candidate for surgical repair. PCH resident had witnessed fall after losing their balance. Fractured hip.

6 Patient at high risk for skin breakdown developed unstageable pressure ulcer to coccyx. No prevention plan identified. PCH resident had unwitnessed fall. Found on floor after bed alarm sounded. Fractured femur and hip. Patient required emergency laminectomy following identification of motor and sensory deficits following epidural catheter removal. Lower limbs paralyzed. Patient presented to the ED with symptoms of a heart attack. No EKG done till 6 hours later. Transferred for emergency angiography. Massive heart attack confirmed. Missed opportunity for diagnosis and early treatment.