External Inquiry into the adverse incident that occurred

76 Pages·2001·0.58 MB·English

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