Adverse Event Summaries 2015-2016
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The Whanganui District Health Board (WDHB) would like to acknowledge and thank the patients and their family members for allowing us to share their stories.
 
The following 17 stories are a summary of the individual adverse patient events that occurred while in our care, the findings from the analysis of the events, and the changes that have been made with the aim of preventing the event happening to another patient.
 
Because the WDHB continually strives to improve patient safety and the quality of care we deliver, we welcome the Health Quality and Safety Commission (HQSC) report to guide us on our improvement journey.
 
The WDHB wishes to also acknowledge the valuable work that the HQSC leads to help us better analyse and learn from our events that cause harm to patients.

 
 
Event summary 1

 
What happened?
A patient was admitted for an elective gynaecology procedure. The surgery was uneventful and the patient made good progress. Two days later, a surgical drain was removed as requested by the surgeon.  When the patient complained of pain following the removal of the surgical drain, the doctor who performed the removal measured it against a new drain and discovered it was shorter. An abdominal x-ray revealed a piece of the surgical drain tip remained inside the patient. That afternoon, the patient returned to theatre to have the surgical drain tip removed. A complaint was lodged about the care the patient received. Findings from the investigation were shared with the patient.

What did we find?
Following a review of the clinical records and speaking with staff, it appeared that three unsuccessful attempts were made to remove the drain. Unfortunately the doctor was unaware the drain had been stitched internally until it had been removed from the drain site with a missing tip. At times, removal of drains and tubes from the body can cause some pain and discomfort. The review found that regular pain relief was charted and given.  At the time the drain was removed, the doctor took the appropriate steps to confirm that the drain tip was inside. In addition, the patient’s medication allergies were not recorded accurately.
 
What did we do?
We ensured an ACC treatment injury claim was lodged. The doctor apologised to the patient at the time for the pain and discomfort when removing the drain. We met with the patient and recorded accurately on our patient management system her medication allergies to alert medical staff in the event of any future hospital presentations or admission.
 
 
Event summary 2

 
What happened?
A patient was being monitored by the Urology Service for raised prostate specific antigen (PSA) levels. Monitoring (which involves regular blood tests and biopsies of the prostate) is continued if the biopsies taken show cells graded six or below. Biopsies graded seven and above require either surgery or radiation treatment. Twelve biopsies taken in October 2014 were reported by the pathologist. Eleven were grade six and one was grade seven. The urologist who read and signed off the report did not notice the grade seven biopsy. Another urologist reviewed the report and informed the patient that the biopsies showed grade six. Arrangements were made for a further appointment in six months. When the error was discovered in August 2015, further tests were undertaken in preparation for surgery or radiation. The patient chose to have surgery in the private sector and made a good recovery.
 
What did we find?
The WDHB’s Urology Service is provided by MidCentral DHB (MCDHB) urologists who travel to Whanganui. This results in patients often being seen by a different urologist at each visit. While the pathologist had used capital letters to highlight the biopsy with a score of seven, this was not responded to by two urologists. The error was disclosed to the patient as soon as it was identified.
 
What did we do?
The WDHB commissioned a review of the Urology Service in order to ensure continuity of care, with a particular focus on responsibilities, systems and processes.
 
We completed an Accident Compensation Corporation (ACC) Treatment Injury claim for the patient so that further treatment could be covered by ACC.
 
 
Event summary 3

 
What happened?
A patient diagnosed with prostate cancer lodged a valid concern about the length of time it had taken for his treatment to begin.
 
What did we find?
Following an in-depth internal team review, it was found that reduced urologist clinical capacity and an individual urologist’s inability to perform the surgery contributed to the delay in scheduling the patient for surgery.
 
What did we do?
The WDHB commissioned a review of the Urology Service provided by MidCentral District Health Board (MCDHB) to Whanganui with a particular focus on responsibilities, systems and processes.
 
 
Event summary 4

 
What happened?
A patient who was 32 weeks pregnant was assessed in the delivery suite to have bleeding. She was examined by a core midwife, and baby’s heartbeat was monitored using a machine called a cardiotocograph (CTG). The CTG results were considered satisfactory so the patient was discharged home and her lead maternity carer (LMC) was notified. At 41 weeks and five days the patient presented in labour to the Maternity Ward. After nine hours into the labour, concerns were raised about the baby’s wellbeing. The obstetrician attended and an immediate caesarean-section was undertaken. Tragically, the baby had died and was unable to be resuscitated.

What did we find?
There was a failure with care planning, assessment and documentation when the woman was in labour and lack of face-to-face obstetric consultant review for unprovoked bleeding during third trimester of pregnancy.
 
What did we do?
We reviewed the management of labour and antepartum (before birth) haemorrhage guidelines and updated staff on the changes. The process of double reading (two staff checking) CTG findings has been implemented. The LMC attended a documentation workshop.
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Event summary 5

 
What happened?
A male thrown from a quadbike presented at Whanganui Accident and Medical experiencing abdominal pain and difficulty passing urine. A CT scan showed he had an extensive pelvic haematoma. A urinary catheter was inserted but urine output remained poor. He was transferred to the Emergency Department and later admitted to the Surgical Ward. When urine output remained minimal, a decision was made to place a three-way irrigation catheter. The catheter was placed by a registered nurse and initially urine output was satisfactory. Later the catheter was found not to be working as expected. A decision was made to remove the catheter but despite attempts to deflate the balloon the catheter could not be removed. The patient was transferred MidCentral DHB where the catheter was surgically removed, his urethra realigned and a suprapubic and indwelling catheter inserted. The indwelling catheter remained in place for six weeks to allow trauma to the urethra to heal. He has since made a good recovery.
 
What did we find?
Following an in-depth internal review it was found that although the three-way irrigation catheter had been placed by an experienced registered nurse, given the patient’s presentation this should have been carried out by the registrar or consultant.
 
What did we do?
A directive about circumstances in which it is not appropriate for registered nurses in the Surgical Ward to place indwelling catheters was given. This includes male patients admitted with traumatic pelvic injury, any patient requiring three-way irrigation, and any post-operative urology patients.
 
Secondly, all junior doctors must attend training on the risks of male catheter insertion. And thirdly, junior doctors are to contact the registrar on occasion when three-way irrigation is being considered as a result of traumatic pelvic injury.
 
 
Event summary 6

 
What happened?
A patient pregnant with her first child who went into spontaneous labour at 39 weeks had a forceps delivery of a live infant. During the forceps birth, a surgical cut in the muscular area between the vagina and the anus (an episiotomy) was performed by a doctor. A second degree tear - not involving the anal sphincter, was recorded in the Maternity Clinical Information System (MCIS). 
 
When the patient went home she initially had poor control of her bowel movements. She went to her GP with ongoing perineal pain and was subsequently seen by a private gynaecologist. Her symptoms indicated a third degree tear - involving the anal sphincter. The patient was urgently referred into the hospital service where she was seen by the same gynaecologist who she had seen privately but not within the correct timeframe. The gynaecologist thought she was here for a second degree tear repair. The confusion led the patient to lose trust in the hospital system.
 
What did we find?
An internal team review of the patient’s care found that staff did not document sufficient details regarding the assessment and repair of the perineum immediately after the birth. The correct process for managing urgent referrals was not followed.
     
What did we do?
Staff have been reminded of the importance of clearly documenting patient assessment details in full. The review findings and recommendations have been shared with the doctor. We have reiterated to staff to check the urgency and category of all referrals, including referrals from private practice.

 
Event summary 7

 
What happened?
A female patient underwent a routine gynaecological surgical procedure.  A few days after discharge, the patient presented to the Emergency Department with pain and other symptoms. She was treated according to her presenting symptoms.
 
Six weeks later she presented back to the Emergency Department with worsening symptoms. A CT scan revealed a surgical clip used during her previous operation, was obstructing her ureter. 
 
The patient required further multiple surgeries and unfortunately continues to have problems requiring treatment at another DHB.
 
What did we find?
An in-depth internal review determined that, while it was identified that a recognised, but rare surgical complication, had occurred during the patient’s gynaecological procedure, we missed an opportunity to diagnose the complication sooner.
 
The review also found that once the complication was diagnosed, insufficient information was given to the family regarding travelling to, and treatment at, another DHB. This made the process confusing and distressing for the patient and family.
 
What did we do?
Whilst it is not possible to mitigate all risk of surgical complications, this event provided opportunity to improve the management of post-surgery presentations to the Emergency Department.  A new guideline has been developed for the department with senior doctors presenting learnings from this case to the team.
 
Further information has also been developed by way of a ’Patient Travel/Te Kawe Turoro information’ pamphlet to ensure that patients and families are aware of what their options are for travel and accommodation support when referred to another DHB.
 
 
Event summary 8

 
What happened?
A patient came to the Radiology Department for an injection in her spine.  The patient had a CT scan to determine where the injection was needed.  Because she was claustrophobic, the patient went feet first into the scanner, instead of the normal head first. The medical radiation technologist (MRT) and radiologist calculated exactly where the injection was needed.  Unfortunately, an error was made in making the calculation and the fact that the patient was feet first in the scanner was not accounted for.  The injection was then given into the wrong side of the patient’s spine.  Later on the same day, the radiologist realised what had happened and called the patient to explain what had happened and apologise.  The patient returned for a second injection in the correct side.

What did we find?
We found that the staff performing CT guided steroid injections did not have a ‘time out’ process in place prior to doing the injections.  A ‘time out’ process provides time for everyone to stop and check what they are doing prior to starting a procedure.  The staff and the patient then go through a checking process to ensure that the injection is being given in the right place.  In addition, we found that staff did not routinely mark the side on patients needing an injection in either the right or left side.
 
What did we do?
We immediately implemented a ‘time out’ process for CT guided injections.  We also added a process (for which the patient is included) which clearly marks the injection sites.  
 
 
Event summary 9

 
What happened?
A male attended the Whanganui Hospital Emergency Department (ED) following a four-day history of testicular pain. Following a review of the ultrasound scan report that had been performed in the private sector that day, obtaining a detailed history from the patient and a physical examination, a diagnosis of infection was made and the patient was discharged home. The patient’s symptoms continued over the next 10 days until he was seen by a private surgeon who referred him back to ED. Further assessment in ED revealed a more serious condition than was originally diagnosed. The patient required surgical intervention.
 
What did we find?
Following an in-depth internal review it was found that the patient had a spontaneously intermittent condition which was not occurring at the time of the ultrasound scan and initial assessment in ED. Accordingly, the diagnosis of a less serious condition was made. However, the review did highlight some minor deficits in the care the patient received and some areas for improvement.
 
What did we do?
The general surgical service guidelines were reviewed and updated to reflect that registrars must inform a senior medical officer about any patient presenting with testicular compromise.
 
 
Event summary 10


What happened?
The patient with planned laparoscopic surgery was observed to be in some pain post operatively. An ultrasound examination showed a dilated ureter and a CT scan showed a surgical clip had been paced on the ureter instead of a ligament. The patient was taken back to theatre where an attempt to remove the clip failed. The surgeon consulted with a urologist and the patient was transferred to MidCentral DHB for ongoing care.
 
What did we find?
The patient’s condition, assessment and treatment were well documented. The surgeon disclosed the error and apologised for this. There was no incident report logged at the time the error was discovered.
 
What did we do?
We lodged an ACC Treatment Injury claim on the patient’s behalf. We discussed with the staff involved, the requirement to document all discussions with the patient and to log incident reports when patient harm has occurred.
 
 
Event summary 11

 
What happened?
A pregnant patient presented in labour at the Whanganui Hospital birthing suite. During labour the LMC called the core midwives into the delivery room to provide extra support and a second opinion. The obstetric doctor was consulted to attend urgently due to absent variability in the baby’s heart rate. The baby was delivered but required resuscitation and transfer to the special care baby unit. The baby was later transferred to Wellington Hospital. After appropriate deliberation and discussion, further attempts at life support were discontinued. Sadly, the baby died later that day.

What did we find?
We commenced a review of the care provided to the patient. Our review identified that there were several aspects of patient care that we could have done better and a number of recommendations were made which we believe, once fully implemented, will improve the care that women and babies receive in the maternity and paediatric services.
 
What will we do?
The actions undertaken have improved, and will continue to improve, the systems and processes involved with foetal monitoring during labour, the systematic response to a maternity emergency and the new-born intensive care and transport arrangements for critically ill infants.
 
 
Event summary 12

 
What happened?
A patient had elective surgery on their left big toe joint. During the procedure the drill bit fractured and the tip remained in the bone.  This was unable to be removed.

What did we find?
There was a delay in notifying the patient.
 
What did we do?
The doctor undertook clinical disclosure with the patient. We have agreed that should any similar incident occur in the future where the piece of equipment can’t be removed it is documented in the patient’s notes that a drill tip has been retained, the patient is advised and the event is notified, either by the surgeon or his delegate, on the incident reporting system, and that the above two actions have been taken.
 
 
Event summary 13

 
What happened?
A patient was admitted as a day case for an elective surgical procedure. Post operatively, whilst in the recovery room, the patient complained of increasing pain. It was noted that there was some oozing from one of the surgical wound sites. The patient was seen by the operating doctor who agreed to keep the patient in overnight for pain management. The pain and ooze which continued overnight was managed by the health care team. The next morning on the ward round, the agreed plan was the patient would stay in overnight and if there was no wound drainage, they would be discharged the next day. Day two following the surgery the patient was discharged home with appropriate plans in place. Day four the patient presented to the Emergency Department very distressed and with increasing abdominal pain. A scan found that a bladder perforation occurred during the laparoscopic surgery resulting in patient re-admission and a longer stay in hospital.

What did we find?
Patient progress postoperatively was well-documented with nurses seeking medical advice as would be expected and doctors responding in a timely way. An incidental quality improvement finding showed the hand written operative report and the anaesthetic record did not meet the current health record procedures requirements applicable to all WDHB employees.
 
What did we do?
The incidental quality improvement finding was discussed with the clinicians involved in providing health care to this patient.  There was no requirement to do any further analyses of this case.
  
 
Event summary 14

 
What happened?
A patient had urology surgery performed due to their having cancer. The histology specimen was sent to the laboratory for analysis. The patient attended a follow-up clinic appointment where the doctor asked for the histology results to be reviewed by a pathologist to determine if the cancer was a low or high grade. The pathologist who completed the review prepared a supplementary report. The pathologist also confirmed that the cancer was actually a high grade in a letter. The doctor became aware of the revised results the day before the patient was returning to another clinic appointment.

What did we find?
The pathology letter written with reviewed histology results was addressed to a urologist at Whanganui DHB. However, the urologist never received this letter as it was scanned into a patient management system when received at WDHB. There was no clear follow up process in place when letters received at Whanganui DHB are for a urologist who is based at another DHB. The supplementary report prepared by the pathologist was never sighted by a urologist.
 
What will / did we do?
The patient was informed of the incident at her clinic appointment. Reviewed histology reports requested by the urologists are addressed and sent back to them at their base DHB. Urologists are reminded that clinical responsibility for signing off of pathology results in a timely manner remains with them. Letters received at Whanganui DHB for a urologist’s attention are redirected to them at their base DHB.
 
 
Event summary 15

 
What happened?
A patient was having laparoscopic (key-hole) surgery and during her surgery, a major blood vessel was damaged, resulting in the patient losing a large amount of blood.  The operation had to be changed to allow the surgeons to find and treat the cause of the bleeding.  The patient was given large volumes of blood and other fluids to replace what she was losing and the hole in the blood vessel was repaired.  After the operation, the patient was transferred to Wellington Hospital and was later transferred to Palmerston North Hospital, before going home. The patient is continuing her recovery and is now returning to work.   
 
The findings of the investigation are due to be shared with the patient.
 
What did we find and what did we do?
As the investigation of this case has only recently been completed, Whanganui DHB will first share the results of the investigation with the patient, before implementing the recommendations from the investigation.
 
 
Event summary 16

 
What happened?
A patient had major abdominal surgery. To help reduce her pain, two continuous regional analgesia (CRA) devices were set up to run into either side of the patient’s abdomen.  The CRA devices were connected to the patient via intravenous tubing which were inserted into each side of the patient’s rectus sheath (abdominal muscles).  Following surgery, the patient was moved to the Surgical Ward where she was cared for.  When it was time to remove the CRA devices and the tubing, the nurse saw the tubing was stitched in to stop it moving.  When she cut the stitch to remove one of the intravenous tubes, she cut through the tubing. The other intravenous tube was removed uneventfully.  Based on an assessment of the situation, the medical team made a decision that the tubing would be left inside the patient.  The patient and her family agreed with the decision and the patient continued with their recovery after surgery.
 
What did we find?
Following a chart review, we found that a type of scalpel has been used to cut the stitches, rather than a specifically designed stitch cutter.  The stitches were described as tight.  We also found that the catheter tubing is often shortened by the surgeon, prior to use, so it was impossible to accurately establish exactly how much was retained in the patient.
 
What did we do?
The patient has been followed up to ensure she is not suffering complications from having the tubing segment retained inside her. The leaders of the Surgical Ward discussed this case in their ward meeting to alert other nurses to get help if stitches are tight or they are struggling to remove them.
 
We have asked the surgeons to consider the use of surgical glue, rather than stitches to hold CRA cannulas in place.
 
 
Event summary 17

 
What happened?
WDHB received notification from the Ministry of Health that ACC’s Treatment Injury branch had made a serious harm notification in a case of delayed diagnosis of a perforated bowel leading to further surgery and ongoing intensive care.
 
What did we find?
Whanganui HDB commissioned a review of the patient’s care which found that the patient’s treatment was appropriate, that she was closely monitored and her deteriorating condition was immediately recognised.
 
What did we do?
We have shared the review of the patient’s care with her to ensure she has a full understanding of the care provided to her by the WDHB.