INCIDENT SUMMARY REPORT

Nature of Incident

Clinical Incident ☒ Non-Clinical Incident ☐ Near Miss ☐

Incident Details

Exact Location: CT Scan Incident Date: 27-NOV-2020 Incident Time:

Department: Radiology Service Area: CT Scan Ward (if appliable): N/A
Narrative Report:
A case of 44 year old male came in for CT scan of abdomen with contrast who developed allergic reaction
secondary to IV contrast. Patient came in with stable vital signs. Given oral contrast which patient verbalizes
unpleasant taste and developed dizziness. Seen and assess by Dr Sulin and transferred him to room1 until
until stable. Patient was placed comfortably at the CT room since he was cleared to push thru with the scan.
A test dose of contrast via IV was given which the patient verbalizes absence of any untoward symptoms.
Full dose was given which after few seconds patient verbalizes difficulty of breathing. Immediately, they
Call for Dr. Sulin in which she assess the patient and immediate action was done. Continue with the scanning
after the patient was stable and was discharged accordingly with stable vital signs.

Incident Cause:
1. probably miscommunication between radtech and doctor
2. anxiety/panic in an urgent situation
3. lack of preparation

Action(s):
1. orientation and discuss on how to improve in such situation and understand each and everyone’s role
2. technical know-how in an emergency situation
3. Prepare needed items ahead of time. Anaphylactic kit,oxygen,patient monitor
4. Mock code, BLS refresher
5. Guidelines for administration of anaphylaxis medication
6. Review of CT scan protocols and guidelines
7. 1 Doctor and 1 Nurse to be on board for all CT scan with contrast cases.
8. Review of an Immediate action of radtech for DOB cases.
Target date: 1 to 2 weeks (1st to 2nd week of December)

Completed By: Anna Vicente Designation: Nurse Manager Report Date:

Staff Involved in Error: Dr. Su lin, Benign, Gale Designation: Doctor, Radtech 03-December-2020