CLINICAL INCIDENT REPORT

QMD-03-004-00
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STRICTLY CONFIDENTIAL UNAUTHORIZED REPRODUCTION OF THIS DOCUMENT IS STRICTLY

PROHIBITED
REPORTING PARTY REQUESTED CONFIDENTIALITY?

YES

NO

INCIDENT NOTIFICATION (to be completed by Department Quality Circle/investigating body)

SUBJECT DETAILS
LAST NAME

FIRST NAME

Mangubat

Leonora Corazon

RECORD/PATIENT NO:

UNIT

186579

5 Main

DATE OF BIRTH

AGE

SEX

06.28.1946

67

Female

PATIENT

VISITOR

EMPLOYEE

OTHER:

PLACE OF INCIDENT (Where did the incident occur?)

UNIT E.G. RADIOLOGY DEPT./6TH FLOOR

SPECIFIC LOCATION E.G. BATHROOM, X-RAY ROOM

DATE OF INCIDENT (MM/DD/YR):

TIME OF INCIDENT:

DEPARTMENT OF SPECIALTY

INCIDENT INVESTIGATION AND ANALYSIS

(to be completed by Department Quality Circle/investigating body)

DESCRIBE THE ACTUAL OR POTENTIAL INCIDENT:

Please include the immediate response and outcome. For medication incidents please state all drugs involved. (Please attach an extra sheet of paper if needed).

Please see attached Incident Report.

DO NOT PUT THIS FORM INTO MEDICAL RECORD

CLINICAL INCIDENT REPORT

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CONTRIBUTING FACTORS
Please include any factors contributing to the incident including: Staff factors e.g. fatigue, skill/knowledge deficit, failure to follow policy, communication problem. Subject factors e.g. mental
condition, social support, aggression, inadequately medicated, over stimulated environment, failure to follow instructions. System factors e.g. access to services, lack of training/policy/facilities.
Consider anything that occurred immediately before the incident.

1.
The nurse was not able to witness the chill episode claimed by the caregiver.
Similarity of Chills & seizure, was mistakenly interchanged.
The signs presented by the patient were described as Asphyxia by the nurse since it was the signs and symptoms witness by the nurse.
(Asphyxia is a condition of severely deficient supply of oxygen to the body that arises from abnormal breathing. An example of
asphyxia is choking. Asphyxia causes generalized hypoxia, which primarily affects the tissues and organs. There are many
circumstances that can induce asphyxia, all of which are characterized by an inability of an individual to acquire sufficient oxygen
through breathing for an extended period of time.)
2.
Immediate response to the patient call should be attended right away.
Chills & Seizure were mistakenly swapped due to some of their some similarity.
3.
Home Instruction should given prior to discharge.

TREATMENT/INVESTIGATIONS ORDERED
E.g. X-ray, Blood test, ECG, EEG, Dressings, New medications, Referral for review by another clinician.

WHAT FACTORS MINIMIZED THE OUTCOME?

HOW COULD THE INCIDENT HAVE BEEN PREVENTED?

E.g. early detection by monitor or alarm. Good assistance, Good plan or protocol,
Consultation or conciliation, do-escalation techniques, use of PRN medication.

E.g. Equipment checks before use, better written or verbal communication, and better work layout/teamwork.

The chills and seizure should be identified properly

- The call should be attended immediately by the one who
receives the call.
The Home Instruction should be written by the concern doctor
prior to the patients discharge or the doctor should advised the
nurse for any additional information they want to give their
patient.

The nurse should be prompt in attending the patients needs,

regardless of the concern.
The nurse should remind the doctors regarding Home Instruction
and the doctors must be consistent in their orders regarding Home
Instructions.

DO NOT PUT THIS FORM INTO MEDICAL RECORD

CLINICAL INCIDENT REPORT

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MEDICAL PRACTITIONERS EXAMINATION OF SUBJECT

Name:

Date:

/ /

Time:

INCIDENT INVESTIGATION AND ANALYSIS

SENIOR STAFF EVALUATION
To allow for full evaluation of the incident, please ensure that all results are available e.g. blood test, X-rays etc.
Describe results of investigation and findings. Please do not repeat a description of the incident

The bedside nurse was not able to witness the chills claimed by the caregiver, thats why he cannot differentiate if its really chills or
seizure. The nurse was able to inform the MROD Dr. Roisa So about what transpire which she acknowledges that it is okay. The nurse
was able to inform the attending Physician Dr Libarnes of the incidence happened, Dr Libarnes then explained to patient and relatives
that the incident was probably signs of choking and not seizure. And that the PDN should know how to perform Heimlich maneuver as
a response if patient exhibit another choking. The bedside nurse was a senior nurse in the Unit, and I can say that he is confident
enough to handle, assessed and respond to the case like this. There was just a confusion with sypmtom that the patient show, which
was the chills that sometimes mistaken as seizure and vice versa.CHILLS is feeling of cold and shivers comes along, while SEIZURE
is an abnormal electrical activity in the brain and accompanied by the symptoms of facial twitching, drooling, eye rolling, muscle
stiffening etc. which was absent in the symptom showed by the patient.
The nurse comes to the patients room every now and then. The nurse was not aware that the caregiver calls the nurse station because
she was on the other patient making her rounds, late at that night she reached the patients room around 11:30pm for routine rounds
and nursing care. PDN told nurse Rianne that the patient had an episode of CHILLS fifteen minutes just before she arrives. The
nurse inquires if she noticed any eye movement or facial twitching (symptoms related to seizure) during the episode of chills but the
PDN replied that there was none of the said above was noticed. The nurse assessed the patient and she found her easily arousal.The
room was really cold and the nurse lower down the temperature of the FCU (Fan Coil Unit) and make sure that the patient was in
comfortable position before she left. No signs of chils was noted during her shift.
There was just a confusion with symptoms that the patient showed, which was the chills that is sometimes mistaken as seizure and vice
versa.CHILLS is feeling of cold and shivers comes along while SEIZURE is an abnormal electrical activity in the brain and
accompanied by the symptoms of uncontrollable muscle spasm with twitching and jerking limbs, shaking of the entire boody,teeth
clenching, temporary halt in breathing, drooling, eye rolling, muscle stiffening,brief black out or the patient cannot remember for a
period of time & etc. which was absent in the symptom showed by the patient. And with the above explanation of the Attending
Doctor, a neurologist , he could easily identify if its a seizure or not.

Home Instruction should come from the doctor of the patient and in this case there was no written Home Instruction to the patient chart
from his Rehabilitation doctor. All home instruction including the medications that were written at the patient chart was given to the
patient by his bedside nurse explaining each Home Instruction from different doctors.The doctor must specify all his special
instructions in the patient chart to served as a reminder both to the nurse and their resident doctor on duty.
DO NOT PUT THIS FORM INTO MEDICAL RECORD

CLINICAL INCIDENT REPORT

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Name: Alona

Signature:

D. Alfaro,RN

Designation: Charge

Nurse

Date &Time: December

6,2013

THIRD PARTY COMMENTS

Please forward this form to any relevant 3rd party area for comments e.g. Pharmacy, Radiology, Laboratory, etc.

Name:

Signature:

Designation:

Date &Time:

DEPARTMENT/SERVICE HEAD OR DIRECTOR COMMENTS

Comment on action taken or needed to prevent recurrence. Comment on resource implications. Please do not repeat the senior staff evaluation.

Did the incident result in an increase of costs or length of stay, or consume extra resources? Please specify:

Name:

Ms. Delia C. Ramos, CCRN, MAN

Designation:

Nursing Division Head

Signature:
Date &Time: December

6,2013

DO NOT PUT THIS FORM INTO MEDICAL RECORD