HLTH 7029 Quality and Safety Assessment 1 :
Rationale: Examining case-studies of real-life quality failings allows for an in-depth exploration as to the causes which led to the event. Case studies provide an opportunity to reflect on the event to identify lessons learnt and develop recommendations to prevent similar future quality failings.
Description: For this HLTH 7029 Quality and Safety Assessment 1 task, students will be asked to critically examine a real-life patient safety failing. Students will conduct an examination of a patient safety failing to identify important insights into key elements of patient safety, identify lessons learnt and to provide recommendations for system
improvements and present their findings in a ’brief’ of the event. Further students should provide recommendations as to quality and safety principles so far in the unit could be applied to prevent similar incidents in future practice.
Hint: Report format Suggested below
Title page (not included in Word count) Abstract 50-100 words
Contents (not included in Word count) Synopsis 100-150 words
Discussion 300-350 words
Recommendations (including basic ideas surrounding implementation) 100-150 words Conclusion 100-150 words
Reference List (not included in Word count)
Hint: Use at least 5 References.
An 80 year old woman died as a result of gas embolism complicating surgical repair of her aortic aneurysm. The 57mm diameter thoraco-abdominal aortic aneurysm was an incidental finding on a CT to investigate the deceased’s ongoing back problems. The aneurysm was compromising the roots of several important abdominal arteries including her renal arteries and surgical repair with a fenestrated endoluminal graft was recommended in light of its diameter and risk of spontaneous rupture. Due to her comorbidities including chronic obstructive pulmonary disease, Stage 4 kidney disease, and mild heart failure, the deceased was referred to multiple specialists to optimise her disease management and assess her suitability for surgery. There was concern over the potential for kidney damage from the use of contrast during the procedure to help identify the location of the aneurysm and affected branch arteries. CO2 gas is routinely used in addition to traditional contrast to mitigate this risk as it readily dissolves in the blood and is expired from the lungs. The deceased’s surgeon had over 15 years of experience with this technique. CO2 is stored in a high pressure cylinder and there is a TGA approved device available to control the flow of gas from the high pressure system to a syringe and from there to the patient in low volume, low pressure aliquots. A two way tap is involved, and it is not possible for gas to flow directly from the cylinder to the patient. The surgeon had found this equipment was prone to failure, and routinely used a device of his own making to perform the same function, also using a two-way tap to prevent any direct path from the gas cylinder to the patient. On the day of surgery, there was no two way tap available, so the surgeon accepted a three way tap, believing that as he would be the only person using the equipment, he would be able to safely control the tap. It is likely that an error was made in controlling the flow of gas via the tap allowing the direct injection of pressurised gas into the
deceased’s circulation, as during resuscitation attempts when the deceased suffered a cardiac arrest mid-procedure, nearly half a litre of gas was drawn from her central venous catheter.
The cause of death was found to be gas embolism and the manner of death by way of misadventure.
An independent expert witness was critical of the decision to proceed with surgery given the
deceased’s co-morbidities and risk of death; however, the coroner acknowledged that the deceased had been keen to proceed with surgery despite the risks instead of living with the fear of spontaneous rupture of the aneurysm. Concern was also raised over the methodology of gas delivery during the procedure, which allowed for inadvertent direct injection of pressurised gas into the deceased’s circulation.
A 36 day old baby died from acute necrotising pneumonia following three brief visits to hospital. The deceased was born at term following a mostly unremarkable pregnancy. Her birth weight was 2.6kg, but she had no problems in the first few weeks of life. She developed a fever and cough when she
was 32 days old and so her parents took her to a small country hospital’s emergency department. There she was noted to be afebrile, with a respiratory rate of 40, oxygen saturations of 97% and a heart rate of 185. The deceased was seen by a doctor, who diagnosed her as having coryza, or a cold, and discharged her home with instructions to her parents to give her paracetamol, and to return if her symptoms worsened.
Two days later she was brought back to hospital by her aunt, who only waited 20 minutes before taking the deceased back home again without being seen by a doctor. The triage nurse did not know about the previous visit to hospital. The deceased was again afebrile, with a heart rate of 110, a respiratory rate of 38, and normal oxygen saturations despite having noticeable nasal flaring and grunting.
The following day the deceased was brought back to hospital by her parents, concerned over her cough and laboured breathing. Again, staff did not recognise that she had presented to hospital twice before. It was a busy day and the deceased and her mother waited nearly one hour in the waiting room before being brought through to a cubicle for a secondary nursing assessment and her first set of recorded vital signs: heart rate 140, respiratory rate 56, oxygen saturation 98% and afebrile. An hour and a half after presentation, the deceased was seen by a final year medical student. He took a brief history, and then offered to help make up another bottle of formula as the deceased’s mother was keen to go home to feed the baby instead of waiting any longer at the hospital.
Despite the medical student’s introduction and explanation, the deceased’s parents thought that he
was a doctor, and were frustrated that he was talking too much and not checking the deceased. They left, saying that they would return the next day for review. That night the deceased was placed in bed between her parents to sleep, and when they woke in the morning, the deceased was not responsive. She was taken to hospital but it was apparent that she had been deceased for some time and resuscitation attempts were ceased. Inquest findings and comments The cause of death was found to be acute necrotising pneumonia with the manner of death being natural causes. Expert opinion was that the death might not have been preventable, but that admission to hospital during
the course of the deceased’s illness would have given her the best opportunity for survival.
On her first presentation, her heart rate was high, and combined with a history of fever could be an early indication of serious infection. Expert opinion was that admission for at least observation would have been advisable, and would have provided the opportunity for full septic screening and the commencement of antibiotics if the fever recurred. However it was noted that the treating doctor had no specialist paediatric training, and had not acted unreasonably by discharging the baby home and asking her parents to bring her back if she deteriorated. It was unfortunate that when the deceased was brought back to hospital, her family did not wait for her to be seen by a doctor and thus missed any chance for admission or treatment.
A 75-year-old woman died from sepsis arising from contaminated pressure sores. She had fractured her hip a few years before her death, and due to her fear of having another fall, spent much of each day seated on a chair. She had trouble with slowly healing leg ulcers, and pressure sores on her heels, thighs and buttocks. She had Type 2 diabetes, requiring insulin, and congestive cardiac failure, both of which contributed to the slow healing of wounds. During a three week admission to hospital her pressure sores were reviewed, and gradually improved. The deceased was provided with a specialised pressure area care cushion and advised about pressure relief for the affected areas; however she did not use the cushion when she returned home.
An Aged Care Assessment Team (ACAT) recommended that she would best be looked after in residential care, but the deceased and her family declined this, preferring to look after her in the family home where she lived with her son. Her daughters lived nearby and helped with meals and housework. The highest level home care package was approved, allowing for personal carers and a nurse to visit three times a week to assist with showering and wound dressings. The deceased managed her own medication doses, with family assistance, and insisted on managing her own dentures. She was incontinent of urine and faeces, and told her family that she was able to change her own incontinence pads without their involvement. At times she refused care of her pressure areas and ulcers. Over the next ten months she was visited at home by a regular team from a private home care service provider. The nurse visiting her home was often hindered by insufficient supplies of dressings from the home care service provider, as well as difficult documentation processes including a lack of integrated progress notes for each client, and no provision of wound assessment forms.
Initially the deceased was relatively active; able to look after her own grooming and toileting, but gradually became less independent and mobile. Increased assistance with bathing was arranged, but the budget allocated in the home care package did not allow for daily dressings of her pressure
sores. Two months before her death the deceased’s pressure sores deteriorated. She was seen at home by a locum GP when she developed a urinary tract infection, but she refused to get up from her chair to allow full examination. She was later seen at a local emergency department with back pain, though it is likely her sacral wounds were not seen by hospital staff.
In the weeks before her death there was breakdown of skin and some very deep sacral wounds. The visiting nurse raised her concerns over these with the deceased, her family, and her manager. The deceased did not change her habit of sitting on a chair for prolonged periods of time. The deceased became quite unwell and after initially refusing to go to hospital, was taken to the emergency department. Concern was raised about her care at home as hospital staff noted the contaminated deep sacral pressure sores, and that her dentures were blackened and discoloured. She had developed sepsis and acute kidney failure. Despite antibiotics and medical management she died a few days later.
The coroner found that death was caused by organ failure due to sepsis from infected pressure sores, and by manner of natural causes. The coroner commented that the infection resulted from deterioration in her condition in circumstances where, due to choices she consciously made, the likelihood of life-threatening infection was significant.
HLTH 7029 Quality and Safety Assessment 1
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