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Written by: Zheng Cuibi
2021-01-28 20:38
Last update date: 2021-01-28 20:39
The Hospital Authority released the latest issue of the "Risk Bulletin" quarterly today (28th). A patient suffering from ureteral calculi was required to undergo ureteroscopy and laser lithotripsy. During the operation, a "lithocoil" device was used to prevent it. The stone fragments moved, but it was only discovered after the operation that a 6 cm long loop was left at the end of the patient's right ureter, which required another operation to completely remove it.
In addition, a patient with type 2 diabetes was supposed to be prescribed 2 units of insulin, but in the end he was prescribed 24 units, and eventually suffered from hypoglycemia. The cause of the incident was "the handwriting is illegible."
"Stone taking coil" device.
(Picture of "Risk Bulletin")
This issue of "Risk Bulletin" mainly analyzes a case of surgical or interventional procedures left behind tools or medical materials in the patient's body, and two cases of inpatient suicide.
In addition, there were 14 important risk events reported, including 12 drug accidents and two cases of misidentification of patients.
The surgeon once straightened the device after the image and then revealed the remaining coil
One of the cases involved a patient who had undergone ureteroscopy and laser lithotripsy due to ureteral stones. During the operation, a "litho-removing coil" device was used to prevent stone fragments from moving. The operating room assistant nurse was retracting the device. Upon encountering resistance, the surgeon tried to straighten the device for removal, and finally successfully removed the device.
However, the postoperative images revealed that there was a fragment left at the end of the right ureter. The fragment was actually 6 cm long and required another operation to completely remove it.
The publication pointed out that when the medical staff encountered obstacles in removing the device, they were unaware that they might break and leave some fragments. They also had no intention of having a round tip on the device. Therefore, no part of the device was found during or after the operation. Disappeared.
The fragments left in the ureter are as long as 6 cm and require another operation to be completely removed.
(Picture of "Risk Bulletin")
In terms of drug accidents, a patient with type 2 diabetes had fluctuating glucose levels and vomiting. He was transferred from the rehabilitation hospital to the emergency hospital. According to a handwritten drug management record from the rehabilitation hospital, the name The patient was prescribed oral hypoglycemic drugs and insulin, and then the patient was prescribed 24 units of insulin three times a day, but in fact he should only be prescribed 2 units of insulin each time.
During the process, a nurse asked why a high dose of "short-acting insulin" was prescribed to the patient. Another nurse responded that because the patient's blood sugar level was very high, the patient was subsequently prescribed two high doses of insulin.
The patient eventually developed hypoglycemia, with a blood sugar level of only 3, and needed 50% glucose intravenous injection.
The publication pointed out that the cause of the incident was that the handwritten records were illegible.
The coil part looks like burnt.
(Picture of "Risk Bulletin")
In addition, a patient was admitted to the hospital because of a persistent cough and a hazy lung X-ray. It was assessed that he was not at risk of suicide. The doctor had suspected whether he had atypical pneumonia.
Three days after the patient was admitted to the hospital, he was missing. The patient's friend later reported that the patient suspected of falling from a height and died on the way to the accident and emergency department of another hospital.
The Hospital Authority General Assembly this afternoon also passed the annual report on medical risk warning events and important risk events (from October 1, 2019 to September 30, 2020). The annual report lists 24 medical risk warning events notified by public hospitals .
In the past year, public hospitals reported 50 important risk events, of which 45 involved medication errors and five misidentified patients or information.
Important risk events refer to events that are promptly detected by medical staff and can be corrected without causing permanent injury or death to the patient.
Inject insulin.
(Profile picture)
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Medical error
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