Download Treatment injury case study

Treatment injury case study
PEG administration error
Event: Medication administration
July 2015 – Issue 78
Injury: Aspiration pneumonia
Wiri, a 65-year-old gentleman, was being investigated for oesophageal varices with
barium swallow.
Wiri had been diagnosed with oesophageal cancer,
and a percutaneous endoscopic gastrostomy (PEG)
tube was required to feed him. The PEG tube had
been inserted after he presented with dysphagia. He
was receiving palliative treatment for his cancer.
Key points
• Always check the right route for medication
administration
• Refer to the five rights of medication
administration:
– Right patient
– Right medication
– Right dose
– Right time
– Right route
• Nurses are governed by workplace policies and
procedures and the New Zealand Public Health
and Disability Act 2000
• Handover is a vital tool for communicating any
information that will benefit the patient and
ensure the nurse provides optimal care
• If anything is untoward, always seek
clarification/legibility or correction of the
medication chart before proceeding with
medication administration
• Errors need to be reported in a timely manner
so that the correct sequence of events can be
recorded
• The reporting of any findings from errors is also
important so that awareness can be raised or
changes in policy be implemented to ensure
best possible practice. Improved processes
result in greater patient safety.
He was taken to the radiology suite where the barium
had been prepared. The radiology nurse gave Wiri the
barium to drink rather than administering it through
his PEG tube. Wiri immediately began coughing and
became short of breath. He was given oxygen by
mask. At this point the nurse realised the mistake
he had made. It was thought that Wiri had possibly
aspirated the barium.
A chest X-ray was done, which demonstrated a right
basal infiltrate, so he was admitted to the medical
ward for ongoing management. He was treated with
nebulisers and fortunately recovered quickly.
A treatment injury claim was lodged for aspiration
pneumonia due to the barium administration
mistake. ACC investigated and accepted the
claim; however, as the injury resolved quickly with
treatment there was little with which ACC could
assist. ACC notified this as an adverse event to the
Director General of Health.
Expert commentary
CE Mitchell, NZ RCpN, Bachelor of Nursing, New
Zealand Nurses Organisation member, PG Cert
Trauma and Emergency Nursing
A PEG tube is not usually seen unless a patient is
undressed or it has been brought to the nurse’s
attention by the patient, at handover or when
reading the medical records.
Nurses need to ensure care around the
administration of medication. The administration of
medication will be guided by the existing workplace
policies and procedures. Medication errors can range
from minor harm to severe and from minimal time in
hospital (with a quick recovery) to long-term hospital
care, permanent disability or even loss of life.
In regards to medication administration, nurses are
governed by not only the workplace policies and
procedures but also the five rights of medication
administration:
Case study
• Right patient
• Other disciplined staff to nurse
• Right medication
• Right dose
• Reading of documentation (such as patient’s
medical records)
• Right time
• Facility to nurse
• Right route
Nurses are required to work from correct and
legible medication charts. If anything is untoward
it is the responsibility of the nurse to either
seek clarification/legibility or correction of the
medication chart before proceeding with medication
administration. This ensures patient safety
and that the correct procedure(s) of medication
administration is followed.
In this case study the RIGHT ROUTE was not adhered
to, causing the patient initial harm. The Nurses’
Code-of-Conduct governs nurses’ practice, and in the
instance of this case study principles 4.9 and 4.10 were
not adhered to.
4.9 Administer medicines and health care
interventions in accordance with legislation,
your scope of practice and established
standards or guidelines.
4.10 Practice in accordance with professional standards
relating to safety and quality health care.
Nurses also need to be aware of the importance of
reading individual patient medical records and/or
the nursing handover. In this case the reading of the
patient’s medical records may have highlighted to
the nurse that the patient had a PEG tube for oral
medications and hence prevented the barium being
given orally.
Another way of ensuring best possible practice is by
using a checklist (this could have been advantageous
to the procedure involved in this case study), to
ensure that the patient’s safety is maintained.
Handover is a vital tool for communicating any
information that will benefit the patient and ensure
the nurse provides optimal care. Handover can come
in many forms:
• Patient to nurse
Errors need to be reported in a timely manner so
that the correct sequence of events can be recorded.
Reporting of any findings from errors is also important
so that awareness can be raised or changes in policy
can be implemented. It is important to ensure that
possible practice and processes are rectified equalling
patient safety.
References/Websites
1. The Code of Health and Disability Services Consumers’ Rights
2. Competencies for Registered Nurses and Practice www.nursingcouncil.org.nz
3. New Zealand Nurses Organisation (2012) Guidelines for Nurses on the
Administration of Medicines
4. Health Practitioners Competence Assurance Act 2003
Claims information
Between July 2005 and June 2015 ACC received 616 claims related to
medication administration errors. Of these, 227 (37%) were accepted and 389
(63%) were declined.
• Nurse to nurse
How ACC can help your patients following treatment injury
Many patients may not require assistance following their treatment injury.
However, for those who need help and have an accepted ACC claim, a
range of assistance is available, depending on the specific nature of the
injury and the person’s circumstances. Help may include things like:
• contributions towards treatment costs
• weekly compensation for lost income (if there’s an inability to work
because of the injury)
• help at home, with things like housekeeping and childcare.
No help can be given until a claim is accepted, so it’s important to
lodge a claim for a treatment injury as soon as possible after the
incident, with relevant clinical information attached. This will ensure
ACC is able to investigate, make a decision and, if covered, help your
patient with their recovery.
ACC7128 ©ACC 2015
In this case study no long-term harm was experienced
by the patient. Reportable events such as this
medication error have historically been caused by
failures to adhere to policies and procedures and/or
best practice. These are typically caused by a number
of factors such as environment, staff experience and
disruptions in workflow.
Printed on stock that complies with environmentally
responsible practices and principles. Please recycle.
The most common reason for declining a claim was that no physical injury
could be identified or there was no causal link between the medication
administration error and the physical injury claimed.
About this case study
Sharing information to enhance patient
safety
This case study is based on information amalgamated from a number of
claims. The name given to the patient is therefore not a real one.
The case studies are produced by ACC’s Treatment
Injury Centre, to provide health professionals with:
•
•
an overview of the factors leading to treatment injury
expert commentary on how similar injuries might be avoided in
the future.
The case studies are not intended as a guide to treatment injury cover.
Send your feedback to: [email protected]