Critical Incidents Reported to Manitoba Health

Size: px

Start display at page:

Download "Critical Incidents Reported to Manitoba Health"

Agatha Joseph
6 years ago
Views:

1 Critical Incidents Reported to Manitoba Health July 1, September 30, 2012 Degree of Patient had a history of vasculopathy & low hemoglobin. Restricted blood supply resulted in vision loss in one eye. PCH resident had pain in eye and discharge from eye. Referred to optometrist who diagnosed an orbital infection. Surgery required to remove eye. PCH resident had unwitnessed fall resulting in fractured shoulder, elbow, hip & pelvis. Not a surgical candidate. PCH resident developed Stage 3 pressure ulcer despite implementation of regional wound care protocols and pressure reduction/redistribution. Heath Care Aide (HCA), who was providing constant care, attempted to assist patient. Patient pushed HCA away, then lost their balance and fell. Fractured pelvis. No surgery required. Patient had unwitnessed fall. Found on floor, unresponsive, bleeding from their head. CT scan showed cervical spine fracture. Surgery performed to stabilize fracture. Patient living with dementia had unwitnessed fall resulting in intracranial bleed. No aggressive treatment indicated. Mental health patient had unwitnessed fall resulting in fractured hip. Surgical repair Patient developed Stage 3 pressure ulcer during hospital stay. PCH resident had witnessed fall resulting in fractured hip. Surgical repair PCH resident had witnessed fall resulting in fractured hip. Surgical repair Home care client developed Stage 4 pressure ulcer. The presence of pain limited movement and repositioning. Patient found to have developed unstageable pressure ulcer. Risk factors included one month history of incontinence, immobility and low albumin levels. Home care client developed Stage 3 pressure ulcer during care. Had fallen one week earlier and was non-compliant with re-positioning schedule. Patient with small bowel obstruction. Arm cool, pale, no radial pulse located. Required surgery for both an ischemic bowel & arm. Patient choked on food. Heimlich Manoeuvre attempted but unsuccessful. Advanced Care Plan (ACP) level indicates desire for comfort care. The patient died. Following hip surgery, signs and symptoms of shock not communicated to the physician in a timely fashion. Patient subsequently died. It is unclear if timely communication would have changed outcome. Patient developed an unstageable pressure ulcer while in hospital. During insertion of intravenous in preparation for diagnostic procedure, patient fainted and struck back of head and spine. Additional diagnostic procedures required. Patient had unwitnessed fall resulting in fractured femur. Surgical repair PCH resident, ambulating independently with walker, had witnessed fall. Fractured femur. Surgical repair Patient, using their walker to ambulate, had unwitnessed fall. Oxygen tubing became entangled around the walker. Fractured hip. Surgical repair Patient developed unstageable pressure ulcer while in hospital. Patient, struck by lightning, was discharged with incorrect medications. Resulting weakness, dizziness and cardiac rhythm disturbance. Re-admitted and correct medications ordered. Recovered and discharged home. Page 1 of 5

2 Patient presented to Emergency Department (ED) with signs of an acute stroke. Seven hour delay in initial Emergency Physician assessment. Window of opportunity for possible thrombolytic therapy missed. Patient developed unstageable pressure ulcer while in hospital. Died 2 weeks later. On investigation, this was found to be a Kennedy terminal ulcer common in dying patients and not preventable. Despite appropriate interventions, mental health patient developed Stage 3 pressure wound to coccyx. Patient received incorrect dose of medication over 18 days. As a result, required blood and platelet transfusions. Hospital stay extended. Patient had complete paralysis following dislocation of cervical vertebrae. Stage 2 pressure ulcer progressed to Stage 4 while in facility s care. Patient receiving palliative care had unwitnessed fall. Found on floor, responsive. Health Care aide went to locate lift to assist with transfer. Oxygen found to be turned off. Patient deceased. PCH resident required amputation of foot following development of an ulcer and subsequent necrosis. Infused CT scan could not be performed due to lack of appropriate venous access. Uninfused CT scan showed ruptured abdominal aortic aneurysm. Emergency surgery undertaken. Patient died in the operating room. Patient with urinary tract infection and low hemoglobin had unwitnessed fall resulting in fractured hip. Surgical repair Patient with cognitive impairment forgot to use their walker. They had an unwitnessed fall resulting in fractured hip. Surgical repair Patient developed Stage 3 & 4 pressure ulcers during hospitalization. Patient developed Stage 3 pressure ulcer to coccyx and heels during hospitalization. PCH resident was being transferred using a ceiling track lift. Strap on sling became disconnected from the lift assembly. Fell to floor fracturing their femur. Patient's gastric tube used for tube feeding found to be positioned in the lung. Diagnosis of aspiration pneumonia. Admitted to ICU for 3 days. Recovered. Patient living with dementia had witnessed fall resulting in fractured hip. Surgical repair During insertion of chest tube, left ventricle of patient's heart was punctured. Surgical repair required. Critically ill pediatric patient developed Stage 3 pressure ulcer to the back of their head. Incorrect implant was inserted during hip surgery. Second surgery required to remove incorrect implant and replace with the correct one. Mental health patient living with dementia, awoke from sleep, got up and had unwitnessed fall. Fractured hip. Surgical repair Patient developed elevated creatinine & potassium levels indicating decreased renal function. Blood pressure medication was not discontinued as indicated. Required acute dialysis & ICU admission. PCH resident had unwitnessed fall striking their head. To hospital for assessment and treatment. Died 3 days later. PCH resident was sitting in wheelchair. Another resident, using a motorized wheelchair, crashed into them with their chair. Resulted in lacerations to both legs requiring consultation with Plastic Surgery. Patient receiving high doses of medication for chronic pain. During surgical procedure, patient did not receive adequate amount of medication for sedation. Patient reports being fully conscious during procedure. Patient found to have Stage 4 pressure ulcer in hospital. Unclear if wound existed prior to hospitalization as no documentation of skin integrity on admission. Patient, living with dementia, developed Stage 4 pressure ulcer one week following surgery. Would often refuse to take pain medication which would allow for re-positioning. PCH resident, independent minded, had unwitnessed fall in room resulting in fractured hip. Surgical repair PCH resident living with dementia had unwitnessed fall. Known to have previous choking episodes. Attempts to clear airway unsuccessful. EMS called. Treated in ICU, but later died.

3 Unknown Patient with advanced liver disease had paracentesis. During procedure, viscus perforated. Developed septic shock. Admitted to ICU. Required hemodialysis. Died 3 weeks later. PCH resident had unwitnessed fall resulting in fractured hip. Family declined surgical repair. Pediatric patient had eye surgery. Received ten times the prescribed dose of Morphine. Resulted in extended hospital stay for monitoring. PCH resident had unwitnessed fall striking head and fracturing hip. Surgical repair Returned to PCH with pressure ulcer to heel and open areas to groins and thigh. During 3 week hospitalization, PCH resident's Stage 2 pressure ulcer deteriorated to unstageable. Mental health patient had unwitnessed fall resulting in fractured hip. Did not request required assistance. PCH resident, with cognitive impairment, had unwitnessed fall resulting in fractured hip. Surgical repair While walking in hallway, PCH resident fell resulting in fractured hip. Surgical repair Pregnant female on methadone program given accidental overdose. Potential for fetal respiratory distress. Prolonged hospitalization. PCH resident developed recurrent unstageable pressure ulcer despite interventions to prevent same. Wound slowly healing with appropriate interventions. Elderly patient underwent uneventful surgical repair of hip fracture. Sudden deterioration in Recovery Room following surgery. Patient died. PCH resident's Stage 2 pressure ulcer to coccyx deteriorated to Stage 3. Pressure relief chair cushion not in use. Surgical debridement of wound required. PCH resident wandering about unit was startled by noise. Stepped backwards and fell. Fractured hip requiring surgical repair. Mental health patient was in seclusion room. Without warning, patient ran head first into the wall. Fractured cervical vertebrae. Surgical decompression of fracture. Now quadriplegic. Patient returned from another hospital following surgery with unstageable pressure ulcer to heel. PCH resident had unwitnessed fall resulting in fractured pelvis. Bed alarm malfunctioned. Patient had unwitnessed fall from wheelchair resulting in fractured pelvis and intracranial bleed. Home care client developed unstageable pressure ulcer. Had refused a pressure reduction mattress when suggested. Likely a Kennedy terminal ulcer as patient died 6 weeks later at home. PCH resident developed an infected pressure ulcer on hip. Medical treatment provided as well as consultation to Plastic Surgery. Client of Family Managed Home Care Program with limited ability to be positioned comfortably developed Stage 3 pressure ulcer. With months of wound care treatment, some healing occurring slowly. Delay in performing emergency C-section for recognized fetal distress. Newborn admitted to NICU. Required transfer to Winnipeg for advanced neonatal care. Patient died while in the care of the hospital. At time of death, there was no known underlying medical condition identified. Medical Examiner was not able to determine the cause of death. Patient's post-operative blister progressed to Stage 3 pressure ulcer. Patient known to have severe circulatory problems. Patient had unwitnessed fall resulting in fractured hip. Surgical repair required. Client receives Family Managed Home Care Services. Requested consultation regarding pain management. Found to have unstageable pressure ulcer to coccyx. Palliative care home care client with rapidly declining medical condition developed unstageable pressure ulcer to coccyx. Page 3 of 5

4 PCH resident had unwitnessed fall resulting in fractured hip. Surgical repair required. Patient developed pressure ulcers to heels during lengthy surgical procedure. Heel gel pads not routinely used during surgery. PCH resident had unwitnessed fall resulting in fractured femur. Surgical repair PCH resident had two unwitnessed falls on the same day resulting in fractured femur. Surgical repair Patient with chronic pain developed unstageable pressure ulcer to coccyx after 12 day hospitalization. Patient with Stage 3 pressure ulcer to foot. Dressings not changed as per wound specialist's direction. Wound deteriorated further. bleeding following C-section resulted in cardiac arrest due to massive blood loss. Emergency surgery to determine and control source of bleeding. Recovered and was discharged some days later. PCH resident developed Stage 4 pressure ulcer to buttocks while in care. During C-section, injury to ureter not detected. Four days later, patient presented to the Emergency Department (ED) with septic shock. Ten days later, required removal of her kidney due to necrosis. Patient had unwitnessed fall resulting in fractured hip. Was found deceased on unit seven hours later. Patient, with history of pressure ulcers to the coccyx, developed a Stage 4 pressure ulcer, open to the bone. Refused both nursing treatment of wounds as well as surgery. Patient had unwitnessed fall from bed resulting in fractured pelvis. No surgery indicated. PCH resident, with vascular dementia, had unwitnessed fall. Initial X-ray showed no fracture. 30 days later, bone scan shows fracture. Surgical repair Patient developed Stage 3 pressure ulcer to coccyx during hospitalization. Significant weight loss prior to admission. Uncooperative with attempts to turn and reposition. Patient with previous urinary tract infections developed septic shock and renal failure due to undiagnosed and untreated urinary tract infection. No signs of urinary tract infection present. Admitted to ICU where patient died 6 days later. Elderly patient, with pelvic fracture, developed Stage 3 pressure ulcer to heel 3 weeks following admission to hospital. Patient had unwitnessed fall. Initial X-ray of hip showed no fracture but pain and immobility persisted. Repeat X-ray detected fracture. Surgical repair PCH resident had unwitnessed fall from chair resulting in fractured hip. Surgical repair Patient had unwitnessed fall resulting in fractured hip. Surgical repair Young patient found unresponsive in bed with absent vital signs. Resuscitation unsuccessful. PCH resident, living with dementia, had unwitnessed fall resulting in fractured hip. Surgical repair Patient underwent procedure to diagnose cerebral aneurysm. A known risk of the procedure is spinal cord ischemia. Three days later, MRI identifies spinal cord infarction. PCH resident had unwitnessed fall resulting in fractured hip.surgical repair CT scan revealed what was thought to be a colostomy was actually the patient stomach. Emergency surgery to correct issue was not performed as the patient s condition was too unstable. The patient died in hospital. Patient presented to the Emergency Department with acute stroke symptoms. Delay in transfer to another facility for intervention as appropriate staff resources not available for transport. Missed window for thrombolytic therapy. Page 4 of 5

5 Young patient with multiple medical co-morbidities, admitted with cellulitis. When condition deteriorated, patient was transferred to ICU. Subsequent cardiac arrest. Unsuccessful resuscitation. Concerns regarding delay in transfer and aggressiveness of care in hospital. PCH resident developed Stage 4 pressure ulcer despite appropriate interventions. No fracture seen by clinician in preliminary x-ray review. When X-ray results read by radiologist, femoral fracture detected. Surgical repair Patient received incorrect treatment due to error in reading of hematopathology reports 2 years earlier. Patient outcome unknown. PCH resident had unwitnessed fall. On assessment, speech found to be slurred speech. To Emergency Department where condition improved. Page 5 of 5

Critical Incidents Reported to Manitoba Health

Critical Incidents Reported to Manitoba Health April 1, 2013 - June 30, 2013 Degree of PCH resident had unwitnessed fall resulting in fractured hip. Found on floor with walker by feet. Surgical repair