Complaints, Errors & Clinical Governance [Case #1]

“Mrs Jones is a 40 year old patient who presented with a laceration to her right thigh sustained as she jumped off a removal van whilst moving house. You assessed her and diagnosed a simple laceration which one of the nurses has started to suture.”

She approaches you now as she thinks she is beginning to get a migraine, she is having visual symptoms so cannot complete her task. None of the other nurses in that area are able to suture so she asks you to take over, the suture kit is open and in a sterile field by the patient and she has already infiltrated the skin with local anaesthetic.

The patient still seems to have significant sensation around the wound so you inject more anaesthetic from the syringe the nurse prepared and used earlier as it is labelled with a lignocaine 1% sticker.

A few minutes later the patient still has full sensation to the skin. Puzzled by this you look around on the trolley for the vial of anaesthetic, but the only thing you find is an empty vial of calcium chloride. After speaking to the nurse it is confirmed that she was sure she got lignocaine out of the cupboard but the vial on the trolley is the one she used, so the patients skin has been infiltrated with the calcium chloride.

Questions

Answer one question before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. The first part of teaching will be spent discussing this case:

1. What are your first priorities in this case?

2. What should you say to the patient?

3. Who else should be told/how else should the event be reported?

4. The patient tells you she wishes to make a complaint about what has happened, what should you say?

5. What factors may have led to this happening? Try to think in terms of systems errors and individual error

6. How could the same error be prevented from happening again in both the short and long term?