ANZCA Bulletin June 2011 - Australian and New Zealand College of ...

Quality and safety continued
(continued from previous page)
equally important to improving quality
and safety. At the recent combined
scientific meeting in Hong Kong a
presentation from ANZTADC regarding
medication errors was given in the
sesssion titled “Development of sound
patient management systems”. This
presentation will be made available on
the ANZCA website.
At the Australian Society of
Anaesthetists’ national scientific
congress in September this year there
will be a session devoted to patient
safety called, “Safety gets the
green light”.
In this session three presentations
will be made. Firstly, “Prevention
and management of assessment and
documentation errors,” by Dr Greg
Deacon. Secondly, “Prevention and
management of respiratory errors,” by
Dr Michal Kluger. And finally, “The
development of new crisis management
tools,” by Adjunct Professor Martin
Culwick. It is also planned to submit a
series of articles for publication in the
Anaesthesia and Intensive Care journal
later this year.
I enjoy maximum flexibility, working
from home when most convenient and
I also very much enjoy face to face
meetings with ANZTADC colleagues. I
am very proud to have been selected to
be involved in the development of the
highest standards for the safety and
quality of anaesthetic practice.
Heather Reynolds
BA, BHlthSc (Nurs), MN, MAP (Health
Care Research), CertTeach, CertCCN
Airway crisis after
extubation
This is the third and final case report
concerning a “can’t intubate, can’t
oxygenate” scenario following
extubation of a patient who had
previously undergone surgical
drainage of Ludwig’s angina.
Similar to the previous reports 1,2 , the
intention is to review the possible
system failures leading to a patient’s
death. It is not my purpose to
criticise individuals. Indeed these
cases are examples of common
clinical management strategies
that occur in many hospitals
throughout Australia and the world.
By examining individual events I
hope to highlight some practices
and suggest alternatives that may
improve our standard of care.
Case report
Patient X was aged 27 years at the time
of his death at a tertiary referral hospital
in Australia. He was in good health
during the months preceding his death
apart from a severe toothache.
He first attended the emergency
department of his local hospital having
had a toothache for the previous week.
He was provided with analgesics and
told to contact the dental clinic that
was part of the nearby tertiary hospital.
Six days after this episode, the patient
returned to the same local hospital
stating that he was still awaiting dental
extraction by the dental clinic. He was
again provided with analgesics and
discharged.
The patient presented a third time
to the local hospital. At this time he
had been suffering from his toothache
for two months. He had been seen six
weeks previously at the dental clinic
at which time he had been informed
that he would have to have the tooth
extracted or repaired. He was waiting for
an appointment time but had not heard
from the dental clinic. The medical
officer at the local hospital described the
tooth as “rotten and shattered” but there
was no sign of infection or abscess. He
recorded that the patient was given
clove oil, Panadeine Forte and injection
of lignocaine. It was recommended to
the patient that he should be seen at
the dental clinic the following day. The
patient’s tooth was extracted in the
dental clinic after this episode.
The day after the patient’s dental
extraction the patient’s mother noticed
that the swelling of his face was
becoming worse and was across his
neck and face. The patient consequently
attended the emergency department
of the local hospital. The patient’s
complaints included swelling to the
lower jaw, inability to open his mouth
and dental pain. At this point there
was no stridor or other evidence of
immediate airway compromise. The
resident diagnosed Ludwig’s angina. He
was to be kept overnight and transferred
to the tertiary hospital the following
morning.
The patient was ultimately
transferred by means of his mother’s
private vehicle to the tertiary hospital
rather than by ambulance. The medical
resident was later asked in the coroner’s
inquest about the appropriateness of
the patient being transferred in his
mother’s car to the tertiary hospital.
He responded that it might have
been considered as the patient had
been stable throughout the night and
there was “a notoriously long wait for
ambulance transfers and non-urgent
patients”.
The admitting doctor at the tertiary
hospital noted that the patient was
able to talk and there was no stridor
or drooling. The patient stayed in the
tertiary hospital emergency department
for 10½ hours. The patient was later
admitted to the ward in the early hours
of the evening. His mother left the
hospital and telephoned the patient
several times during the late afternoon
and evening. She noted that her son was
having difficulty speaking on the phone
to her during this time.
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ANZCA Bulletin June 2011