Key Takeaways:
- A serious incident at Auckland Hospital resulted in a man sustaining a life-altering injury, including paraplegia and suspected mild hypoxic brain injury.
- The incident involved the incorrect insertion of a chest drain, leading to massive blood loss, shock, and cardiac arrest.
- An investigation found moderate to severe departures from standard care, including inadequate leadership, poor communication, and a lack of nursing staff.
- The hospital’s policy on chest drain insertion has been updated, and an audit of recent procedures has been recommended to ensure informed consent is obtained.
- The incident highlights the importance of proper training, communication, and adherence to protocols in medical procedures.
Introduction to the Incident
The Deputy Health and Disability Commissioner, Dr. Vanessa Caldwell, has released a report on a serious incident that occurred at Auckland Hospital in 2022. The incident involved a man who was rushed to the emergency department with multiple internal injuries and broken bones after a car accident. Despite the severity of his injuries, the man did not have any evidence of a cervical spine fracture. However, during his treatment, a serious incident occurred that resulted in the man sustaining a life-altering injury.
The Incident Unfolds
The man was admitted to a critical care unit and later transferred to the general surgery ward under the trauma service. Doctors were concerned about his ongoing increased respiratory and heart rates, and a scan showed a moderate build-up of fluid in his chest and lungs. A senior trauma specialist recommended that the fluid be drained, but the imaging request could not be accommodated by the interventional radiology team. As an alternative, a chest ultrasound was scheduled to indicate where the drain should be inserted, but it didn’t go ahead because the man was in too much pain to be moved. The procedure was rescheduled for the following day, and a decision was made to insert the chest drain at the bedside using the Seldinger technique.
The Procedure Goes Wrong
The Seldinger technique involved inserting a hollow needle into a body cavity, followed by a round-tipped guidewire, and then a catheter. However, the guidewire and chest tubes did not pass smoothly, and there was no nurse present to assist and monitor the patient’s pain, distress, and clinical deterioration. The two trauma fellows, a surgeon and a physician, took over the procedure, and dark, "old-looking" blood was aspirated. While suturing the drain to the man’s chest wall, he became "very sweaty," and the emergency bell was activated. The man’s condition deteriorated, and a code red medical emergency was called, which was later upgraded to code blue, indicating cardiac or respiratory arrest.
The Aftermath
The man lost about four liters of blood and had lost cardiac output. He was given at least five minutes of CPR, and his aorta was clamped for about five to seven minutes before he was rushed to theatre for emergency surgery. A CT scan confirmed that the drain had been inserted incorrectly, traveling through the liver and into a nearby vein. The man developed ischemic bowel and spinal cord injury, causing paraplegia from mid-back level, and suspected mild hypoxic brain injury. The investigation found that there was no written informed consent documented for the chest drain insertion.
Investigation Findings
The investigation found moderate to severe departures from standard care, including inadequate leadership, poor communication, and a lack of nursing staff. The surgeon and physician at the time of the incident were found to have made moderate departures from standards, and the surgical registrar was also found to have made a moderate departure for not speaking up when he thought the procedure was unsafe. However, this was mitigated by his handing over care to the more senior clinician when he felt out of his depth. Health NZ disputed some of the findings and recommendations, but the Deputy Health and Disability Commissioner recommended that the hospital update its chest drain policy and conduct an audit of recent procedures to ensure informed consent is obtained.
Conclusion and Recommendations
The incident highlights the importance of proper training, communication, and adherence to protocols in medical procedures. The Deputy Health and Disability Commissioner’s report emphasizes the need for healthcare providers to prioritize patient safety and well-being. The recommendations made in the report, including the update of the chest drain policy and the audit of recent procedures, aim to prevent similar incidents from occurring in the future. The incident also serves as a reminder of the importance of transparency and accountability in healthcare, and the need for healthcare providers to learn from their mistakes and make improvements to their practices.