Patient needed plastic surgery after getting chemo drug

A patient had to undergo plastic surgery after suffering a chemical burn and tendon damage from a chemotherapy drug they were given while being cared for by the Lakes District Health Board.
The Interim Board of the Health Quality and Safety Commission has released the 2009/2010 Serious and Sentinel Events Report and in the Lakes District Health Board area there were seven serious and sentinel events in that period.
The report found a patient had been given a chemotherapy drug that caused a chemical burn and tendon damage requiring plastic surgery and ongoing physiotherapy. It further reported a mental health patient was able to use a previously unfilled prescription and collect more medication to commit suicide.
The report also highlighted incidents such as patient falls, a surgical swab being left inside a patient and other clinical management problems.
The seven incidents compare with three for the 2008/2009 year and six for the 2007/2008 year.
Lakes District Health Board quality and risk manager Lesley Yule said the focus remained on actively learning from serious and sentinel events and putting in place systems and processes to avoid incidents from happening again.
Two of the incidents were unwitnessed falls and both have been used to drive quality improvements across Rotorua and Taupo hospitals. The improvements include:
Installing soap dispensers in all showers to reduce risk of falls.
Establishing a falls professional advisory group to implement initiatives that reduce falls.
The ongoing purchase of equipment to support patient safety.
Three of the events were clinical management problems but the board has made quality improvements since, including: Nursing education on assessment, planning, intervention and evaluation of patient care. Purchasing another bladder scanning machine to make sure equipment is available to nurses in the right place at the right time.
The development of a protocol for difficult cannulation (tube insertion).
The preparation of written patient and medical information on complications of intravenous chemotherapy drugs.
The review of current processes for clinical handover of patients.
New swabs that can be detected by x-ray machines are now being used at the hospitals and a more structured procedure for counting the amount of swabs being used is also being trialled.
The health board is also developing a process around a patient's personal medication supply when admitted to Rotorua Hospital.
The board welcomes feedback from the public, which should be addressed to the Quality and Risk Team.