The Hospital Authority published the latest issue of "HA Risk Alert" last Friday. In the second quarter of 2017 (April to June), 13 Sentinel Events were reported, comprising nine cases of retained instruments after surgery/interventional procedure, two cases of in-patient suicide, one case of maternal morbidity and one case of incompatible blood group transfusion. There were 11 reported Serious Untoward Events, which were all medication incidents.

One of the Sentinel Events involved a patient who underwent craniectomy and gross total removal of the cerebellar arteriovenous malformation for recurrence of small residual supplies from the right superior cerebellar artery and posterior inferior cerebellar artery. Six days later, computed tomography (CT) of the patient’s brain showed suspected foreign body. One Raney clip was subsequently removed from patient’s subcutaneous layer at bedside.

The Raney clips not included as accountable item in the current practice is cited as one of the key contributing factors. The report also points out there are variations in the practice of removal of the Raney clips.

The Raney clips. Photo credit: HA Risk Alert
The Raney clips. Photo credit: HA Risk Alert

Another Sentinel Event involved a patient who had fracture right ring finger after a crush injury 4 weeks ago. Open reduction and internal fixation with K-wire and tension band wiring to the right distal phalange was performed for the patient. A pull-out loop metal wire was applied together with a protective axial K-wire. 6 weeks postoperatively, K-wire and pull out wire were removed at the Hand Clinic uneventfully. No follow-up X-ray was arranged for the patient on that day.

Yet, the patient attended follow-up 4-weeks later and complained of persistent pain over right ring finger. X-ray showed retained broken wire loop over previous pull out wire site. The broken wire loop was then removed in an urgent operation the following day.

Retained loop wire. Photo credit: HA Risk Alert
Retained loop wire. Photo credit: HA Risk Alert

The report highlights the low awareness on high risk of wire loop retention from breakage of pull-out wire. It recommends reinforcing the practice of checking the integrity of removed pull-out wire and comparing the wire with previous radiological images. It also suggests adopting a low threshold for ordering radiological confirmation of complete removal of wire loop in case of doubt or difficulties encountered in the removal process.

"Subsequent to incident review and analysis of the root causes of these incidents, important lessons for patient safety were identified, while recommendations have been made and shared in this publication to avoid similar events in future," the HA spokesperson said. MIMS

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