External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th PDF
Preview External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th
External Inquiry into the adverse incident that occurred at Queen’s Medical Centre, Nottingham, 4th January 2001 by Professor Brian Toft BA (Hons) Dip Com Sci (Cantab) PhD MInstD FIRM FIIRSM FIOSH Hon FICDDS CONTENTS Chapter 1: Introduction 9 Background to the adverse incident 10 The patient 10 Ward E17 11 Hazard awareness of Vincristine 11 Protocols 12 Labels 12 Packaging and supply of cytotoxic drugs 13 Protocols and guidelines 13 Nursing staff 13 Physical appearance of syringes containing cytotoxic drugs 13 Chapter 2: Provision of chemotherapy for the Day Case Unit 15 Sterile Production Unit 16 Dispensing Cytotoxic Drugs 17 Intravenous Administration of Cytotoxic Drugs 17 Intrathecal Administration of Cytotoxic Drugs 18 Senior House Officers 18 Codes of practice, Protocols and Guidelines 18 Specialist Registrars 19 Day Case Co-ordinator 20 Professional Experience of Staff Involved 20 Chapter 3: Chronology of events 23 Tuesday 2nd January 2001 23 Wednesday 3rd January 2001 23 Thursday 4th January 2001 24 Ward E17 24 Mr Jowett’s prescription 24 Ward E17 24 Sterile Production Unit 24 Thursday afternoon 25 Collection of Mr Jowett’s chemotherapy 26 Admission to Ward E17 26 Proceedings leading to the adverse incident 27 Chapter 4: Analysis 30 Tacit Assumptions 30 The medical team involved in the adverse incident 30 Senior Medical Personnel Ward E17 33 Nursing Staff Ward E17 34 Pharmacy Staff 35 Day Case Coordinator 37 QCM Drug Custody and Administration Code of Practice 37 Discussion 37 1 External Inquiry into the adverse incident that occurred at Queen’s Medical Centre Nottingham 4thJanuary 2001 Chapter 5: Conclusions and Recommendations 40 Conclusions 40 The adverse incident 40 System Failures 40 Safety Culture 40 Operational practices 41 Protocols 42 Administration 42 Training 43 Communications 43 Technical 43 National Issues 44 Recommendations 44 Operational practices 44 Protocols 45 Administration 46 Training 46 Communications 47 Technical 47 National issues 47 References 49 Appendices 51 2 List of Plates Plate 1 A reconstruction of the labels affixed to the syringes. Plate 2 Photograph of a pre-filled syringe containing Vincristine illustrating the warning written inblue text. Plate 3 A photograph of two similar syringes to those used in the procedure. Plate 4 A reconstruction of how the two syringes would have looked in their respective packaging. Plate 5 Reconstruction of the bag of chemotherapy dispensed to Ms Shanahan. Plate 6 A reconstruction of an intrathecal procedure. 3 External Inquiry into the adverse incident that occurred at Queen’s Medical Centre Nottingham 4thJanuary 2001 A reconstruction of the labels affixed to the syringes – Plate 1 4 Plates A photograph of two similar syringes to those used in the procedure – Plate 2 Photograph of a pre-filled syringe containing Vincristine illustrating the warning written in blue text – Plate 3 5 External Inquiry into the adverse incident that occurred at Queen’s Medical Centre Nottingham 4thJanuary 2001 A reconstruction of how the two syringes would have looked in their respective packaging – Plate 4 Reconstruction of the bag of chemotherapy dispensed to Ms Shanahan – Plate 5 6 Plates A reconstruction of an intrathecal procedure – Plate 6 7
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