CIA report: Patient Collapse and Expiry

Title: Collapse and expiry of Patient Muhammad Umar in Cardiac male Ward
Incident Date: 13/02/2024
Incident Location: Cardiac Male ward bed 1
Name: Saqib Khan
Enrollment # 4-4/2020/010

Background:
This report is the analysis of an incident that happened on my LM clinical duty. The incident happened on
13/02/2024 Tuesday in male cardiac ward. It involves a patient Muhammad Umar, who with dengue
fever, SOB, and left ventricular hypertrophy. The patient was on BiPAP but it was removed overnight to
check if the patient is able to maintain oxygen or not. Staff Sheeza gave the BiPAP to the CCU staff as
they needed it, ignoring the doctor orders of putting the BiPAP on the bed side for SOS need.
Purpose and Scope: The main purpose of the report is to

 Analyze different circumstances that leads to the collapse and death of Mr Umar.
 To find out the contributing factors and root causes.
 To recommend some measures that may be helpful in prevention of such incidence.
Importance of the analysis for improvement and learning.
This incident reflects and will help in understanding:

 Importance of improving the patient’s safety.

 Identifying and improving the weaknesses of communication in our hospital.
 The importance of readily availability of the equipment at the bed side.
 The importance of proper documentation of every event.
Detailed Narrative and sequence of events that led to the incident:
12th Feb Night Shift:

 Mr. Umar was taken on face mask oxygen removing his BiPAP support to check if he will
maintain saturation.
 The doctor ordered to keep the BiPAP on the bed side for SOS use.
 Staff Sheeza gave the BiPAP to CCU staff in night shift without documenting or reporting it.
 Staff Sheza gave patient over to staff Bilal without mentioning about the BiPAP situation nor did
he ask about it
13th Feb Morning Shift:

 Staff Bilal was not aware of the BiPAP, and he did not inform the morning shift nurse Staff
Maryam.
  Due to over of 4 patients staff Maryam also did not notice the BiPAP and suctioning order in the
file.
 The patient had very thick secretions. He was needed to be suctioned through airway for deep
suctioning, the staff Maryam and student Nizar only did oral suctioning.
 The patient was on 5L of oxygen and they had put the oxygen mask on the patient head for very
long time.
 Patient was in supine position instead of severe SOB.
At 9:00 AM: While on round I Staff Mumtaz observed that:

 Patient’s oxygen mask was misplaced and he was in wrong position.

 Oxygen saturation was 57%, after the doctor’s assessment blue code was called out.
Complications in Intubation attempt:

 Doctor decided to intubate the patient before shifting to MICU.

 The tube of the suction point was blocked due to a thick clot in it.
 I asked the doctor to pinch the clot in the tube, but the doctor insisted that suction point is
malfunctioned
 We changed the suction point but the block was still there.
 Staff Tariq squeezed the tube that removed the clot and suction started.
 After intubation patient was shifted to MICU but the oxygen tank was empty.
 Despite all the efforts the Patient lost his life in MICU.
Involved individuals:

 Staff Sheeza
 Staff Maryam.
 Staff Bilal
 Staff Mumtaz
 On duty resident.
 Student Nizar.
 Student Saqib khan.
 Patient Muhammad Umar.
Immediate action:

 Patient was intubated but it took too much time.

 Patient was shifted to MICU.
Analysis:
Root Cause Analysis:
Lack of communication and inappropriate handover: Lack of verbal communication and
documentation of removal of BiPAP and its presence at bedside. Improper system of handing over the
patient.
Missed monitoring and assessment:
During oral care. Improper assessment of respiratory distress of the patient by staff.
Lack of interventions and equipment malfunction:
Staff ignored the need of suctioning through airway, blockage of the suction tube after intubation, and the
empty O2 cylinder.
Analysis of human factors

 Staff Bilal’s as a intern inability to take over properly and check every order including BiPAP had
the most potential impact.
 Staff sheeza ignoring the order of keeping the BiPAP on the bed side for SOS use.
 A high nurse to patient ratio in my case it was 1:4 that led to low level of concentration over all
patents.
 Staff Maryam and student Nizar ignoring the suctioning through airway which led to severe SOB
and respiratory failure.
 Lack of proper communication during handing over the patient.
 Inability of the doctor to clear the suction tube on time.
Systems Analysis:

 Improper documentation system from the staff as well as the doctor.

 Workload management and staffing level : there is a clear impact of workload and staffing level
on the handing over of the patient the staff rushes to give over to another staff so that they can go
early.
 Their is lack regular checks of equipment and lack of training for the use of these equipment
Risk assessment:
Harm to the patient and death:
This incident led to the death of patient Muhammad Umar. And it highlighted the potential consequences
of communication breakthrough, late interventions , and malfunction equipment.
Psychological distress: The event caused psychological distress to the patient’s attendant he even
damaged hospital property in MICU. He was not in his right state of mind. It also caused emotional
trauma to the family.
Impact on hospital reputation: Events like this may greatly impact the hospital reputation, the word of
mouth can spread really fast.
Findings:
Good communication and documentation of events is very important and crucial for the safety of the
patient, specially the documentation of critical equipment, history of the patient, and during handing over
of the patient.
Clear handover of the patient , appropriate staff to patient ratio, and a proper and affective incident report
system is very important for proper information sharing, observation of the patient and learning from such
incidents.
Action Plan:
Immediate Actions:
  Incident was reviewed with the staff who was involved.
 Staff Shaheed from NES came and gave teachings on the importance of proper handing over of
the patient. The main focus was on paper communication between staff and doctors, proper
documentation, use of equipment and it’s regular check, the importance of working as a team in
emergencies.
 Guarantee investigation of the incident: Over all investigation of the incident , which included
equipment and oxygen cylinder issue.
Short-Term Actions:

 Seminars will be arranged by NES department regarding effective communication , handing

over , management of equipment, and procedures of emergency responses
 There will be equipment status check every 2 days.
 Ward Incharge will supervise the handing over of the patients.
 Staff needs will be addressed, and one extra staff will be assigned in cardiac ward.

Long-Term Recommendations:

 Their should be a handling over card which the staff should give to the next shift staff. That card
should include all the essential information that will lead to proper handling over and less miss
communication between staff.
 Regular audits should be conducted regarding equipment, oxygen cylinders and crash trolley
 Open communication should be encouraged.
 Proper protocols should be implemented for regular check and maintenance to prevent such
incidents in future .
Monitoring and Evaluation:

 The implementation of the action plan should be tracked as well as it’s affect on the
documentation, communication, management of the equipment and ensuring patient’s safety.
 Open communication should be encouraged along with reporting of concerns to identify to
maintain and identify issues.
Conclusion:
This incident shows that how important is clear communication, proper documentation, regular check of
equipment status, and the role of team work in such events. By insuring the the proposed action plan and
creating such environment where everyone should be able to communicate with each other and learning
though that environment. The hospital should try to prevent such incidents in future and ensure patient
safety along with staff safety.