Seven steps to patient safety The full reference guide. Second print August 2004

Transcription

1 Seven steps to patient safety The full reference guide Second print August 2004

2 National Patient Safety Agency Seven steps to patient safety 113 Appendix Four F Examples of events according to severity 1. No harm: Impact not prevented General A patient is prescribed one painkiller (e.g. paracetemol) and given two instead. This has not been prevented in any way but has not caused any harm in this particular case. Problems with blood taking bottles causing false readings and irregular results with the potential for wrong diagnosis blood retested. Two patients with the same name have their records amalgamated; this is picked up when the patient is seen again (either in outpatients, inpatients or GP clinic) before any incorrect diagnosis or treatment. Very small perforation of the bowel during surgery, no content leakage; the perforation is repaired quickly and abdominal area appropriately washed out; no further operations or therapy required. Normal saline infused in two hours rather than four hours due to the wrong setting of the infusion pump, causing no harm to the patient. Two patients who require a blood transfusion both with the same blood type, patient A receives patient B s transfusion and vice versa, with no ill effects. A patient is given someone else s medication; however, the medication was identical to their own prescribed medication so this caused no ill effects. A patient is receiving warfarin as an outpatient and the GP surgery fails to monitor clotting levels according to protocol. The patient mentions this at a later date and when they are finally checked, they are found to be within normal limits. A patient is on medication that requires regular blood tests; the hospital discharge letter fails to mention this to the GP which results in the patient not being followed up appropriately. However, it is noted when the patient visits the GP for a further prescription. The patient s results are then found to be normal. crew is called to a patient at home with chest pain and gives the patient an aspirin, without asking if they are on any other medication. They are then informed that the patient is on warfarin. There are no adverse effects for the patient.

3 114 Seven steps to patient safety National Patient Safety Agency 1. No harm: Impact prevented A porter collects a patient to go to theatre. As he is leaving the ward a nurse recognises that the porter has collected the wrong patient and another patient with the same name should be taken. This is corrected and the right patient goes to theatre. A patient is nearly given someone else s medication; however, the nurse double checking the patient s identification realises the mistake and does not give the patient the medication. A patient rings their GP practice for a follow up appointment to monitor warfarin levels, an appointment letter is sent, but would have been forgotten if the patient had not rung. A GP prescribes an inappropriate dose which the local community pharmacy picks up when dispensing the prescription. An ambulance crew is called to a patient at home with chest pain and want to give the patient an aspirin; just before administration they are informed by the patient s relative that the patient is on warfarin. The aspirin is not given.

4 National Patient Safety Agency Seven steps to patient safety Low General A patient trips and falls in the hospital corridor, resulting in a wound which requires stitches and a dressing. A child receives out of date feeds causing slight vomiting. Perforation of the bowel during surgery, repaired at the time and area appropriately washed out, only antibiotic therapy required. A patient s operation is cancelled as a result of poor pre-admission assessment (e.g. clotting status) but this has minor consequences. Patient receives a small bruise from a towel clip being clipped to the patient s skin as well as the towel during surgery. A patient is given someone else s medication; the medication was the same as the patient normally takes but a slightly higher dose, which resulted in the patient needing to go to bed earlier than normal because of drowsiness. levels; this results in prolonged clotting times, causing bruising. A patient s home visit is missed; the terminally ill patient required a pain assessment; this was picked up the following day resulting in the patient continuing to be in pain until the medication was altered. An ambulance crew is called to a patient at home with chest pain. On arrival the crew decides to administer oxygen to the patient and is then informed that the patient has had a laryngectomy. There are no laryngectomy masks on the vehicle so the crew have to attempt to oxygenate the patient using a face mask over the stoma. On arrival in A&E the patient s oxygen saturation levels have dropped from 92% to 85%.

5 116 Seven steps to patient safety National Patient Safety Agency 3. Moderate Perforation of the bowel during surgery not picked up at the time, which results in septicaemia and a return to theatre for repair. Patient eats prior to surgery, causing urgent operation to be cancelled, which leads to deterioration and longer stay in hospital. Wrong blood is given resulting in emergency dialysis. However, there are no long-term effects. A patient s broken foot is not detected on x-ray and the patient is sent for extensive physiotherapy which causes further pain and damage. A patient is given someone else s medication; the medication is stronger than their own and the patient suffers prolonged drowsiness. The patient needs frequent observations of their respiratory rate. levels which results in an overdose and bleeding problems. Patient with external infusion line (e.g. Hickman line) gets an infection while at home following repeated disconnections, requiring a hospital admission for antibiotic therapy. An ambulance crew is conveying a patient from the ambulance to A&E on a trolley bed. The patient is left unattended for a short period and the trolley bed tips over. The patient suffers short-term loss of consciousness and needs to be admitted to hospital for observation.

6 National Patient Safety Agency Seven steps to patient safety Severe Perforation of the bowel during surgery, requiring a temporary colostomy and subsequent major operations. Problems with blood transfusion (e.g. transportation) resulting in the blood not arriving in time, patient suffers brain damage following haemorrhage. Wrong blood given to a young woman, who then develops anti-d antibodies which will affect any future pregnancy. Removal of wrong organ or wrong limb due to mis-identification. A patient is given someone else s medication which they are allergic to. The patient suffers an adverse reaction, has a cardiac arrest and suffers brain damage as a result of receiving this medication. levels which results in a brain haemorrhage and brain damage. A newborn baby with an inborn error of metabolism fails to be screened for phenylketonuria resulting in irreversible brain damage. A patient incurs an extravasation injury (soft tissue burn) from an intravenous line at home, causing irreversible scarring and bone damage. Failure to diagnose meningitis by GP or A&E department, child is discharged home, then collapses which leads to permanent brain damage. An ambulance is called to a patient who has fallen from scaffolding. On arrival the patient is conscious but lying awkwardly, his leg is clearly fractured. Before undertaking a full assessment on the patient the ambulance crew repositions the patient to straighten his leg, without undertaking any immobilisation to the cervical spine. After repositioning, the patient is unable to move any of his limbs and investigations later identify that he had a cervical fracture and spinal cord damage. The cervical spine was, however, immobilised immediately after repositioning. He is likely to suffer long term with paralysis from the neck down.

7 118 Seven steps to patient safety National Patient Safety Agency 5. Death Death as a direct consequence of perforation of the bowel during surgery. Pacemaker battery change is undertaken by a person with no expertise causing the patient to have a cardiac arrest and then die. Wrong blood is given resulting in multi-organ failure and death. Death as a direct result of a hospital-acquired infection. A patient is given someone else s medication which they are allergic to. The patient suffers an adverse reaction, has a cardiac arrest and dies as a result of receiving this medication. A suicide or homicide on healthcare premises. levels which results in a brain haemorrhage and death. A patient suffering from chest pains is asked to wait for a free slot; he goes for a walk, collapses and dies in the GP car park. An ambulance is responding to an emergency call on blue lights and is going through traffic lights which are on red at a crossroads. A car travelling on the road crossing which has got a green light does not see the ambulance and carries on over the crossroads. The ambulance is unable to stop in time and hits the car on the driver s side. The driver of the car has multiple injuries and later dies in hospital.