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A patient required an enema before surgery. The patient immediately suffered from severe generalized abdominal pain. The enema was stopped and the event investigated. It was found that the hospital, due to water shortage, had stored water in various jerkins and the one used for the enema still had large amounts of a disinfectant (gluteraldehyde).
- Dec 04, 2015 09:12:53
A middle aged lady went to the emergency room of a hospital with a broken patella. She was operated on by the on-call orthopedic surgeon. A week later she had her stitches removed and was asked to come back after one month to check the healing of her fracture. During that visit she complaint to the orthopedic surgeon that she could barely bend her knee. The orthopedic surgeon asked her if she was getting physiotherapy. Surprised, she replied that nobody advised her to have physiotherapy.
The orthopedic surgeon had been practicing for a long time in Europe and recently came back to practice in Egypt.
- Dec 04, 2015 09:12:08
A patient developed dyspnea during a prolonged postoperative period. The patient was put on oxygen and a CT examination of the chest and abdomen was requested by the managing doctors. The patient was taken to the radiology department to have the CT examination. The radiology technician faced with a dyspneic patient and no oxygen, requested that an oxygen cylinder be brought to the patient first. An oxygen cylinder was delivered, however, it turned to be empty. A second oxygen cylinder was delivered which was full, however, no tools were available to connect the cylinder to the oxygen delivery system. By that time the patient became cyanosed and suffered from cardiac arrest.
- Oct 10, 2015 09:10:16
Two patients with the same diagnosis were scheduled for surgery on the same day and same time. They were anesthetized by the same anesthetist. They were operated by two different surgeons. After surgery and while documenting their operative notes each surgeon discovered that he had operated on his colleagues patient. Luckily it was the right surgery.
- Sep 05, 2015 10:09:33
A surgeon scheduled two of his patients to undergo surgery. One patient was scheduled for tonsillectomy while the other was scheduled for an ear surgery. After he completed the two surgeries and while writing the operative notes he discovered that he had performed the ear surgery instead of the tonsil surgery and vice versa.
- Aug 13, 2015 02:08:00
A patient was prescribed an intravenous amino acid: Dipeptiven as part of his postoperative treatment. Dipeptiven, at the time, was not available at the hospital pharmacy. The patient family ordered the medication from a friend pharmacist through the mobile. The pharmacist dispensed a hypnotic: Deprivan (sound-alike) instead of Dipeptiven. Unfortunately, the wrong medication was given to the patient leading to acute respiratory failure and ICU admission.
- Jul 24, 2015 08:07:26
An elderly patient underwent endoscopic esophageal stenting. A sealed scalpel blade was used to mark the stricture level by fixing it to the patient’s back with adhesive plaster. The patient was discharged after the procedure, however, he complained of back pain and contacted his doctor who advised him to have an X-ray on his chest. The x-ray report stated that a surgical scalpel blade was retained within the patient’s chest. The patient alarmed by the diagnosis contacted his doctor who advised him to see him immediately. The doctor checked the patient’s back to discover that the surgical scalpel blade was still attached to his back. The doctor removed the surgical scalpel blade and assured the surprised patient that everything was alright.
- Jun 11, 2015 10:06:50
A patient undergoing a major surgery suddenly developed cardiac arrest. After successfully resuscitating the patient and completing the surgery, the surgical team in attempt to understand what went wrong discovered an open and empty ampoule of potassium chloride. The team came to the conclusion that the ampoule must have been mistaken for distilled water when preparing medication for the patient.
- May 01, 2015 08:05:54
A patient on large dose corticosteroids developed deep vein thrombosis. She was admitted as an emergency case to a public hospital around noon time. Five hours later she had not been seen buy any doctor. Her family asked the nurse in charge about the expected time the doctor was going to see her. They were surprised to know that the doctor was going to see her next morning. Faced with this level of care they asked to be discharged and went to a private hospital where she was immediately admitted to the intensive care unit!
- Apr 19, 2015 11:04:59
A surgeon electively prepared a patient for surgery based on an orally reported CT examination. The patient was anesthetized and the assistant surgeon opened the patient while the surgeon was reviewing the digital images of the CT examination. The surgeon discovered that the digital images do not fit with the oral report that he previously received. Faced with this problem, the operating team had to wait for two hours while the right digital images were sent from the radiology center before they could resume the surgery.
- Apr 02, 2015 03:04:56
A urinary catheter was inserted to a patient as part of the required care. Staff noticed that the patient was not producing any urine as evident by lack of urine in the collecting bag. A urologist was consulted who confirmed the proper position of the urinary catheter. Staff in charge started to give the patient fluids and medication in an attempt to push the kidneys to produce urine but with no result. Patient was then diagnosed with acute renal failure and blood withdrawn to confirm the diagnosis and steps were taken to schedule the patient for hemodialysis. During the course of events the patient was complaining of lower abdominal pain and ultimately the patient involuntarily passed stools. During patient cleansing from resultant soiling the urinary catheter was disconnected from the collecting system resulting in the free flow of a large amount of urine. It became apparent that the collecting system was blocked because it was connected to the urinary catheter with its cap on!
- Feb 10, 2015 05:02:43
A healthcare provider was given the task to administer insulin to all diabetic patients in a ward. Protocol states bedside estimation of blood glucose level before administrating the appropriate dose of insulin. Faced with this task and with shortage of blood sampling needles, the healthcare provider used each patient’s insulin syringe needle to obtain the required blood sample and also to withdraw the appropriate dose of insulin from the ward insulin vial.
- Jan 06, 2015 05:01:27
A patient underwent excision of the thyroid gland for a multinodular goiter. The patient was discharged after a smooth postoperative period. However, the patient complained of the persistence of the swelling on one side of the neck. The patient was diagnosed with incomplete removal of the gland and underwent a second surgery. During the redo surgery it was discovered that the swelling was a small piece of gauze that had been retained in the thyroid gland bed during the first surgery.
- Dec 01, 2014 04:12:56
A patient suffered from severe shivering after endoscopy. When revealing possible causes it was discovered that opened propofol ampoules were kept in the fridge for reuse.
- Nov 01, 2014 01:11:26
A lady had a fine needle aspiration (FNA) from a lump in one of her breasts. The result of the FNA stated the presence of malignant cells in the aspirate. As a result, she had a mastectomy. The final pathological examination of the removed breast did not reveal any malignancy.
- Oct 11, 2014 06:10:28
A women in a public hospital was referred to the radiology department to undergo an abdominal ultrasound free of charge. She was given an appointment after 24 hours and was instructed to take anti-flatulence medication till the examination. Her husband, on his own initiative, also requested to have an abdominal ultrasound on his own expense. To his surprise he was given an immediate appointment without any preparation.
- Sep 01, 2014 09:09:38
An endoscopy unit was getting towards the end of their working day. While the last patient was recovering from the endoscopic examination the unit staff started to close the unit. The staff member responsible to shut the unit checked on the patient in the recovery area and told him that it was time to leave the unit. The patient supported by his wife left the recovery area after which the staff member shut the unit. A few hours later the hospital security heard loud shouting from inside the unit. The security, with their emergency keys, opened the unit to discover that the patient and his wife were locked inside the unit. It transpired that the patient and his wife on their way out from the unit went to the toilet area without being noticed which resulted in them being locked in the endoscopy unit for several hours.
- Aug 04, 2014 07:08:40
At 10 PM a lady was admitted to the outpatient of a hospital suffering from acute pain in her right leg. The doctor examined her and found that she was suffering from acute ischemia in her right lower limb. The doctor asked her to go to the X-ray department to have a Doppler examination of her lower limbs which he documented in the X-ray request but without writing the clinical diagnosis.
The lady went to the X-ray department and was given an appointment after 24 hours. The lady returned to the doctor who contacted the X-ray department to inform them of the urgency of the investigation. The X-ray department technician agreed and she had the investigation performed by the department doctor at 1 PM which showed occlusion of the arteries of her right leg and foot. The X-ray doctor informed the patient’s escorts the results of the investigation without explaining the critical nature of the situation. The patient’s escort informed the outpatient doctor about the diagnosis who ordered an immediate CT angiography on both lower limbs. The patient returned to the X-ray department to have the CT angiography done after doing a blood analysis for urea and createnine levels. The CT angiography was performed at 3 PM and the patient received the CT films without a report at 5:30 PM.
The patient was advised to go to another hospital as there was no vascular surgery in the hospital where she was diagnosed. She went to the new hospital, however, it appeared to be a wrong hospital. She then went to the right hospital and appeared at the emergency department where she was admitted at 7 PM. She started to receive specific treatment for the ischemia at 11 AM when she was examined by the hospital consultant.
- Jul 22, 2014 12:07:32
An insured patient with advanced hepatic cirrhosis, ascites and an obstructed para-umbilical hernia was admitted to a medical ward at 12:00 noon. At 13:00, surgical consultation was requested. A surgical resident within the next hour evaluated the patient and contacted his senior consultant at 14:00. By that time no consultants were available at the hospital to promptly evaluate the patient. At 17:00 the senior consultant examined the patient and decided that the patient was suffering from a strangulated hernia and is in need of an urgent surgery. The patient was operated upon at 22:00 when blood and plasma became available as requested by the on duty consultant surgeon. At surgery a gangrenous intestinal loop was found in the hernia necessitating resection anastomosis.
- Jun 13, 2014 10:06:09
A patient with a history of previous falls was admitted to hospital. The patient woke up in the early hours of the morning to go to the bathroom. On his way out of the bathroom he fell and hit his head. One of the other patient’s relatives in the ward heard him fall and called for help. As a result of the fall the patient suffered from a fissure fracture of the skull, multiple hematomas and bruises. The injuries did not require intervention. The patient had difficult relations with his family and that is why he was on his own in the hospital.
- May 06, 2014 10:05:37
An eight month old baby girl started to complain of chest infection. She had a plain x-ray which did not reveal any significant radiologic features. She was admitted to hospital for 11 days to treat her chest infection. The problem persisted after discharge and a second chest x-ray was performed. A safety pin was seen on the X-ray film and was claimed to be used for fixing her dummy to her clothes. However, the radiologist noticed that the safety pin was open. By examining the baby girl no safety pin was found. The old X-ray was reviewed and the same open safety pin was seen. It was then realized that the baby girl had swallowed the safety pin a while ago. An endoscopy was performed and the safety pin was removed from the oesophagus.
- May 06, 2014 10:05:58
A newly qualified nurse was working under the supervision of a senior nurse. The senior nurse asked the new nurse to administer insulin to the diabetic patients in the ward. The new nurse asked the senior nurse, who was talking on her mobile, whether to administer the whole syringe or not. The senior nurse replied positively to that question. So the new nurse administered the whole syringe primed with long acting insulin (100 units) to two patients. When approaching the third patient; it was commented by a relative that he usually does not take a whole syringe of long-acting insulin. The new nurse with the patient’s relative consulted the senior nurse and it was discovered that the patient’s relative was right and that the new nurse had given high doses of long acting insulin to the previous two patients. Faced with this situation, the two nurses decided not to report the incident and instructed the two patients to consume large amount of sugar hoping that this will control the situation. At the end of their shift they informed the night shift nurse about the situation. The night shift nurse did not report the incident and performed frequent blood sugar analysis to the two patients. At the early hours of the morning the two patients started to suffer from signs of hypoglycemia when their blood sugar levels fell to 20 and 30 mg / dl. At this time the night shift nurse decided to report the incident to the resident on duty. The patients were given IV glucose 25% and the situation was then controlled.
- Mar 18, 2014 07:03:19
Two patients with the same diagnosis of piles were admitted to hospital into the same room. One patient had his surgery on the day of admission while the other was scheduled for the next day. The nurse in charge during the night shift asked the ward orderly to administer an enema to the patient awaiting his surgery. She informed the orderly that the patient was laying on the bed near the window. The orderly went to the patient and informed him that he was to administer him an enema. The patient, although astonished, complied and the orderly discovered that he was going to administer the enema to the wrong patient. It appeared later that the two patients has swapped their beds for comfort reasons.
- Mar 15, 2014 09:03:51
A nurse asked a hospital worker to help her administer medication to some of her patients. She gave the worker an antibiotic suppository and told him to give it to one of her patients. After some time, the patent appeared at the nursing station stating that since he swallowed the medication he feels that it is stuck in his chest (oesophagus)!
- Jan 03, 2014 09:01:31
A patient required urinary bladder cauterization before surgery. The resident requested the nursing team to prepare the necessary equipment so he could insert the urinary catheter. When he arrived at the ward he found that a nurse trainee had inserted the urinary catheter, however, the patient was in pain. The resident, who was also in his induction period, re-inserted the urinary catheter. After surgery, it was noticed that no urine was present in the collection bag. The catheter was removed and a significant amount of blood came out of the urethra. It was then realized that the patient had suffered from an iatrogenic injury of the urethra earlier in the ward.
- Dec 27, 2013 10:12:14
A young boy was admitted to hospital because of inability to swallow, regurge / vomiting and dehydration. He was given IV fluids and his chest and abdomen X-rayed. The X-rays were unremarkable except for the presence of a zipper handle on the chest X-ray, which was attributed at the time to the clothes that he was wearing while being X-rayed. The boy was discharged with no definitive diagnosis, however, after several days he was readmitted with the same complaint. The same procedures were repeated and the chest X-ray, again, revealed the zipper handle. Reviewing the old X-rays and the boys clothes; it was immediately realized that the boy had swallowed the zipper handle. An upper endoscopy was performed confirming the diagnosis and the zipper handle was removed safely.
- Nov 14, 2013 06:11:37
A patient underwent a surgical resection of a segment of the jejunum. The distal end of the anastomosis was used to create a feeding jejunostomy. The patient had two tube drains one connected to the feeding jejunostomy and the other to the peritoneal cavity. Instruction were given to start enteral feeding. During a routine round on the patient it was discovered that the feeding was initiated through the tube drain connected to the peritoneal cavity and not the tube drain connected to the feeding jejunostomy.
- Oct 01, 2013 08:10:34
A young boy presented to the emergency department with an acute abdomen. He was urgently operated upon revealing generalized peritonitis secondary to a perforated appendix. The appendix was removed and the peritoneal cavity lavaged. He had a smooth postoperative course and was discharged from the hospital within a week. A few months later he presented again to the emergency department with high fever, abdominal distension and raised white blood cell count. Clinical and radiological assessment pointed towards the diagnosis of a pelvic abscess. He was urgently operated upon to reveal a large concealed pelvic abscess with a retained swab in the pelvis from the previous exploration.
- Sep 18, 2013 07:09:04
An inpatient was receiving a low molecular weight heparin (LMWH) injection every 12 hours. The ward nurse administered his morning dose at the appropriate time when she was informed by the patient that the evening shift nurse had administered a similar injection just before the end of the evening shift. The ward nurse checked the medication charts which showed that the patient was receiving a 12 hourly injection of LMWH and had received his evening dose at the appropriate time. To clear this conflict, the ward nurse contacted the evening shift nurse (later) who revealed that she had forgotten to give the patient his evening dose and when she remembered (at the end of her shift) she administered the injection before leaving the ward.
- Aug 06, 2013 06:08:22
A patient was admitted to hospital suffering from hematemesis. The managing team diagnosed him with bleeding oesophageal varices. A Sengstaken-Blackemore (SB) tube was inserted and inflated to control the bleeding. Forty eight hours afterwards he was scheduled for an upper gastrointestinal endoscopy. Prior to endoscopy the SB tube was deflated, the anchoring adhesive plaster removed from the patient’s nose, and the tube extracted revealing a severely ulcerated tip of the nose with areas of necrosis.
- Jul 19, 2013 04:07:23
أجرى جراح عملية إستئصال للمرارة على إثنين من المرضى على التوالي أثناء الفترة الصباحية من عمله. تبين وجود ورم خبيث بالمريض الأول و حصوات بالمريض الثانى. تحدث الجراح مع أسرة المريض الأول و أبلغهم بالنتيجة الغير متوقعة و هى وجود ورم خبيث بالمرارة. قبل مغادرة المستشفى، زار الجراح المريضين بغرفتيهم. بدأ الجراح بزيارة المريض الثاني وفوجئ بأن عائلته في حالة من الصدمة. أدرك الجراح على الفور أنه أبلغ الأسرة الخاطئة عن الورم الخبيث الغير متوقع
- Jun 27, 2013 02:06:59
A patient suffered from a perforation in his duodenum while undergoing a therapeutic endoscopic procedure. The patient was operated upon and then admitted to the ICU. During his stay he developed several infections. He started to receive a combination antibiotic intravenously every 12 hours based on the culture and sensitivity results done. While receiving his fifth injection the patient suffered from sudden onset of cardiac arrhythmia leading to cardiac arrest and death.
- May 04, 2013 11:05:17
A patient arrived at an endoscopy unit to undergo endoscopic examination of the upper gastrointestinal tract. The receptionist could not find his name in the unit registry. After questioning his accompanying nurse, it was discovered that the patient was an inpatient from another hospital and was scheduled to have an endoscopic examination in that hospital but by mistake was taken to an endoscopy unit of another hospital.
- Apr 05, 2013 09:04:27
A patient was undergoing a scheduled balloon dilatation of a benign biliary stricture. After successful dilatation of the stricture the endoscopist was unable to remove the balloon from the patient (biliary tree) although the nurse endoscopist deflated the balloon. Faced with this situation, the endoscopist tried to remove the balloon with the help of a stone crusher thinking that it would burst the balloon making it possible to remove it. However, the attempt failed resulting in breakage of the catheter with the distal part containing the balloon and two thirds of the catheter stuck to the biliary tree. The endoscopist was able to insert a biliary stent beside the stuck balloon catheter thus ensuring biliary drainage. The endoscopist decided to stop at this stage and when the patient recovered from the anesthetic he explained to him what had happened and recommended a wait-and-see policy to which the distressed patient agreed. One month later, the patient informed the endoscopist that he had passed the balloon catheter while defecating.
- Mar 09, 2013 05:03:02
أثناء إحدى النوبات شديدة الحركة، سألت الممرضة تومرجى العنبر أن يساعدها فى توزيع علاجات النوبة على مرضى العنبر. وكان أحد المرضى مقرر له لبوس مضاد حيوى. ظهر المريض بعد فترة فى محطة التمريض شاكياً من صعوبة فى البلع حيث أن العلاج الذى تلقاه قد علق فى حلقه. وظهر أن المريض قد ابتلع اللبوس معتقداً أنه من المفترض أن يؤخذ عن طريق الفم بدلاً من الشرج.
- Feb 04, 2013 08:02:30
A 60 years old male patient with end stage renal disease on maintenance hemodialysis, developed difficulty in breathing and chest discomfort two and a half hours after his mid-week dialysis session , and was found to have hypotension. He had experienced no problems during his previous dialyses with the same dialyzer and circuit, and had been hemodynamically stable prior to starting dialysis. The machine conductivity was within the normal range and no alarm was triggered.
At the time of this event he was found to be acidotic and hyperkalemic. He was admitted to ICU, treated with a dopamine drip and sodium bicarbonate infusion. After hemodynammic stabilization a hemodialysis session, using bicarbonate buffer and another machine, was conducted. All the metabolic abnormalities were reversed and the patient was discharged in stable condition
The bicarbonate inlet line of the machine was subsequently found to be blocked by deposits of bicarbonate.
- Jan 07, 2013 05:01:40
A patient who was admitted to hospital had a chest X-ray. The X-ray revealed multiple lung consolidations (pneumonia). The doctor in charge initiated a course of antibiotics and ordered a CT chest for the patient. To his surprise the CT chest revealed normal lung fields. When reviewing the chest X-ray report and film it was realized that the name on the chest X-report was correct while the name on the X-ray film was wrong and belonged to another patient who was actually suffering from pneumonia. After several inquiries, it became clear that the X-ray films were put into their folders and incorrectly named which resulted in the X-ray reports being incorrectly named. Meanwhile, the diagnosis and treatment of the patient with pneumonia was delayed as he, due to the X-ray mix, was wrongly diagnosed to have clear lung fields.
- Dec 13, 2012 07:12:39
A patient underwent a therapeutic endoscopy through the oral cavity (ERCP) under rapid acting intravenous anesthesia. The procedure was successful and the patient was discharged and given a follow-up appointment after one week. At the follow-up visit the patient complained of pain in her jaw with limited movement and inability to completely close her mouth which affected her ability to eat and drink during that week. Examination of the patent revealed that she was suffering from jaw dislocation which was not diagnosed at time of discharge the previous week. The patient was referred to a specialist unit where her jaw was reduced into its proper place.
- Nov 04, 2012 05:11:31
A newly appointed nurse was responsible for transfusing a unit of blood to one of her patients during an afternoon shift. The nurse in preparation of the blood for transfusion asked a relative to the patient to warm the blood by keeping it close to her body. The relative, of medical background, noticed that the name of the patient on the blood unit pack was different from the name of her relative patient. The relative immediately notified the nurse who revised the data on the blood pack to notice that the blood unit pack label has dedicated space for two names; one for the patient and the other for the blood donor. Furthermore, she discovered that not only was she going to transfuse the blood to the wrong patient but also that she had misread the donor’s name on the blood pack as the patient’s name. The first two names of the concerned patient in this story were similar to the first two names of the blood donor on the blood pack.
- Oct 01, 2012 07:10:36
A patient had a minor operation in the left lateral position under rapid intravenous anesthesia. The patient was left to recover in this position. During his recovery the patient unconsciously changed his position into the supine position resulting in his fall from the operating table onto the floor. As it was difficult at the time to assess whether the patient suffered from concussion as a result of the fall it was decided to keep the patient under observation in the hospital for 24 hours. When reviewing the adverse event it was clear that all members of the healthcare team in the operating room had left the patient to recover under no close observation.
- Sep 01, 2012 07:09:56
A surgeon working in an endoscopy unit scheduled a patient for a hernia surgery and told him to meet him at the endoscopy unit on the morning of the surgery. The patient arrived at the unit and was told to wait at the reception area. The patient noticed that several other patients in the reception area were being taken care of while he was left with no progress. He volunteered to one of the auxiliary staff that he was here to be taken care of and not to be neglected while other people are being taken care for. The auxiliary staff seeing that the patient was right, in being left for a long time, took him to the endoscopy procedure room. He asked him to change his clothes in preparation to undergo an endoscopy when the patient volunteered that he came to the hospital to undergo a hernia surgery.
- Aug 01, 2012 01:08:02
مريض بالقسم الداخلى يعانى من صعوبة بالتنفس تقرر علاجه عن طريق جلسات استنشاقية. عندما كانت الممرضة المسئولة تقوم بتحضير العلاج الإستنشاقى له تم إستدعائها لمناظرة مريض آخر بحالة حرجة فقامت بترك السرنجة المعبأة بالعلاج الإستنشاقى بعربة تنفيذ العلاج. أثناء متابعتها للمريض الحرج طلبت من زميلة لها إعطاء المريض الاول مدر للبول. قامت الممرضة الأخرى بحقن المريض الأول وريدياً بالسرنجة المعباة من قبل الممرضة الاولى ظناً منها إنها تحتوى على مدر للبول. إكتشفت الممرضتان الخطأ الذى حدث فى نهاية النوباتجية عند مراجعة العلاج. المريض لم يعانى من أية مضاعفات.
- Jul 01, 2012 01:07:33
A patient was scheduled to undergo a therapeutic endoscopy (ERCP) to remove a stone from the bile duct. The endoscopist nurse responsible for the procedure arrived at the unit and noticed that an endoscope was in the disinfecting machine and assumed that it was the duodenoscope required for that procedure. The patient arrived at the hospital as scheduled and was taken to the operating room and given an anesthetic.
When the endoscopist nurse removed the endoscope from the disinfecting machine she discovered that it was a colonoscope that had been used earlier on. When she went to look for the duodenoscope she discovered that it was not available in the unit.
It was found out that the duodenoscope had been lent to another hospital earlier this day and was on its way back to the hospital. One and half hour later the duodenoscope arrived at the hospital and the procedure was then performed.
- Jun 01, 2012 09:06:20
I’m a doctor and so is my husband. He suffered from acute appendicitis and was admitted to hospital and an appendicectomy was performed immediately.
He was then transferred to his ward room where he complained that the Air Conditioner was not working properly and asked to be transferred to another room which was done. After two days he noticed that he was taking three types of medications. One, he assumed, would be an antibiotic, the other probably an analgesic, but he wondered what would the third one be? He decided to inquire and it turned out that the third medication (to our surprise) was related to treatment of prostatic hyperplasia.
When he further inquired about the reason for being prescribed such a drug for a young man, he found out that this drug was intended for the former patient residing in this room who was moved to another room. It became clear that the hospital uses room numbers as part of their policy for patient identification.
- May 01, 2012 04:05:46
تم وضع مريض بوحدة الإفاقة للملاحظة بعد إجراء عملية إسئصال الطحال. نظراً لإنشغال جميع الأسرة بوحدة الإفاقة تم ملاحظة المريض و هو على عربة الترولى داخل الوحدة. تم تثبيت كيس التجميع الخاص بقسطرة فولى البولية بجانب عربة الترولى. للأسف وقع المريض من على الترولى حيث أنه بدون حواجز جانبية و أدى ذلك إلى إنتزاع القسطرة من المثانة البولية. نتج عن ذلك نزيف بالجهاز البولى و لكن أوضحت الأشعة عدم وجود أى إصابات بمجرى البول فتم تركيب قسطرة بولية جديدة لحين وقوف النزيف. شفى المريض دون مضاعفات.
- Mar 31, 2012 10:03:49
An obese patient was operated upon to repair his abdominal incisional hernia using an onlay mesh. On the first post-operative day, the surgeon noticed that the suction drain was not yielding any discharge and the patient was suffering from abdominal pain. The surgeon revising the operative steps in his mind recalled clamping the suction drain from inside the abdomen to ensure proper placement of the suction drain but did not recall removing the clamp by himself although the operating nurse confirmed right count of the instruments at the end of the operation. The patient was taken to the radiology room, where an abdominal X-ray revealed a retained clamp. The patient was taken to the operating room to remove the clamp which was found clamped to the suction drain in the subcutaneous space. The patient recovered with no complications. It was found later, that there was a change in the operating nurse during surgery.
- Mar 06, 2012 08:03:38
تم تركيب لمريض خضع لعملية جراحية بالبطن قسطرة وريدية مركزية بالوريد الوداجى الداخلى الأيسر و قسطرة فوق الجافية للتحكم فى الآلم بإستخدام مادة البيوبيفاكين من خلال مضخة سرنجية. .تم تثبيت لقسطرة الفوق الجافية على ظهر المريض و على كتفه الأيسر بإستخدام لاصق طبى.
كانت سياسة المستشفى الحفاظ على المرضى داخل وحدة الإفاقة لحين إزالة القساطر الفوق الجافية. ولكن بسبب عجز فى أعداد هيئة التمريض تم إخراج المرضى من وحدة الإفافة إلى عنابرهم بنهاية الوردية الصباحية. لم يتم تدريب جميع أعضاء هيئة التمريض بالعنابر على رعاية القساطر الفوق الجافية و على كيفية إستخدام المضخات السرنجية.
تم إخراج المريض إلى عنبره بالقسطرة الوريدية المركزية و القسطرة الفوق الجافية فى أماكنهما. أثناء مرور رئيسة هيئة التمريض على العنبر فى نفس اليوم خلال وردية الظهيرة إكتشفت أنه قد تم توصيل المضخة السرنجية التى بها مادة البيوبيفاكين بالقسطرة الوريدية المركزية وليس بالقسطرة الفوق الجافية. لحسن الحظ فإن المريض لم يعاني من أي أحداث عرضية نتيجة ذلك الخطأ.
- Jan 09, 2012 03:01:36
أنا ممرضة و لى قريب يعانى من سرطان الدم كان محجوز بالمستشفى بسبب إعياء شديد. إتصلت شقيقته بى تطلب حضورى الفورى للمستشفى و ذلك لعدم وجود هيئة تمريض كافية للقيام بالأعمال المطلوبة. هرعت إلى المستشفى و سألت الممرضة الموجودة عن كيفية المساعدة. أخبرتنى الممرضة أنه يمكن مساعدتها بنقل وحدة دم كانت معدة لقريبى. أخذت وحدة الدم من الممرضة وعلقتها على حامل بجانب سرير قريبي إستعداداً لتوصيلها بجهاز نقل الدم. فجأة، لاحظت أن فصيلة الدم المدونة على وحدة الدم ليست فصيلة قريبى التى كنت أعرفها مسبقاً. راجعت الإسم على وحدة الدم فأكتشفت أنه مشابه لإسم قريبى الأول و الثانى فقط و لكن مختلف عن باقى إسمه. ذهبت مسرعة إلى الممرضة لأخبرها بما إكتشفته فإتصلت بموظف بنك الدم الذي أكد أن وحدة الدم الخاصة بقريبى مازالت موجودة ببنك الدم و أن وحدة الدم التى كانت ستعطى لقريبى تخص مريض آخر.
- Dec 02, 2011 11:12:29
An anesthetist during work asked his colleague to give him an IV antibiotic because he was starting to suffer from a sore throat. His colleague agreed and an IV catheter was inserted in his forearm and the antibiotic prepared (diluted). However, as soon as the antibiotic was being injected the anesthetist started to scream from severe pain. His colleague thought that the catheter was misplaced and the antibiotic was being administered subcutaneously. However, the catheter was found to be properly placed and when the situation was further investigated it became apparent that the antibiotic was diluted using potassium chloride.
طبيب تخدير أثناء عمله طلب من زميله أن يعطيه مضاد حيوى بالوريد لإنه بدأ يعانى من إحتقان بالحلق. وافق زميله على طلبه و تم تركييب كانيولا بالوريد و إعداد المضاد الحيوى. ما أن بدأ الزميل فى حقن المضاد الحيوى حتى صرخ الطبيب بصوت عال من شدة الألم. إعتقد الزميل أن الكانيولا ليست بالوريد و أن المضاد الحيوى يحقن تحت الجلد. ولكن إتضح أن الكانيولا فى مكانها الصحيح و عند دراسة الموقف أكثر إتضح أن المضاد الحيوى قد تم تحليلة يإستخدام أمبول كلوريد البوتاسيوم.
- Oct 31, 2011 03:10:13
Two qualified doctors were attending a three day training course away from their home town. On the second day of the course one of the doctors suffered from acute gastroenteritis (nausea and vomiting) most probably from a meal he ate in one of the fast food chains during the first day of the course. The sick doctor asked his colleague to help him administer an intravenous anti-emetic drug because he was feeling sick and did not want to start vomiting. His colleague went to the nearest pharmacy and bought the drug and necessary equipment. After injecting his colleague with the drug, it was discovered that the drug that was administrated was not the required anti-emetic drug but a non-steroidal anti-inflammatory drug.
- Aug 19, 2011 11:08:37
Patient identification failure:
A patient was scheduled to have a cholecystectomy because of gall stone disease. The patient arrived late to the hospital. Meanwhile, another patient with gall stone disease appeared at the hospital operating room (to consult about his future cholecystectomy). The staff in the hospital who at the time were looking for the first patient took the second patient into the operating room and a cholecystectomy was performed. When the first patient arrived late at the operating room, the staff recognized that they had operated on the wrong person but luckily had performed the right operation.
- Apr 16, 2010 11:04:30
I attended a meating a few weeks ago where diagnostic errors regarding pathology specimens was mentioned. Has anybody confronted such a situation before? Please advice on what can be done to prevent the recurrence of such a problem.
Nabil Dowidar
- Jul 07, 2009 09:07:54
It was a pleasure to see that number of patient safety believers inASPA meeting today;04/27/2009.
And, as I heard today in the open part of that session ,I hope to cosider the different specialiries, intrests, and the different motives to be active sharers in APSA activities , and to avoid their frosteration and to use education , cross-learning, and communication strategies to broaden the " Circle of Believers",I suggest The APSA Steerind Committee to adopt , in addition to its 2009 target Project (Safe Surgery Saves Lives) collect, evaluate, select some or all of their experiences and/or ideas in the domain of PS and to assign these projects to them in parallel to APSA Year-To-Year Program that should compass other service areas, and involve Primary Care and other outpatient services and community settings. This might help get aggregate data, successes , and database for ASPA for Peer and Comparative issues.
DR.Refaat SAKR
Quality Directorate -HIO General Director
- Apr 27, 2009 04:04:20
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