Group 17

Closing the Loop - December 2020


To all St Vincent’s clinicians, I'm pleased to share the second in a series of communications sharing lessons learned in clinical practice at St Vincent’ Health Australia.

Mistakes are made by competent, careful, and caring providers every day. By sharing key findings from reviews completed by you and your teams with the wider St Vincent’s community, we aim to encourage staff to anticipate issues and to apply interventions that might prevent an adverse event or ameliorate harm.

Professor Erwin Loh
Group Chief Medical Officer
Group GM Clinical Governance St Vincent’s Health Australia
December 2020

Case 1 Serious Harm – Diathermy Burns

Standard 5 Comprehensive Care

5.1 Clinical governance and quality improvement to support comprehensive care.

The case highlights the importance of clinicians using the safety and quality system from the Clinical Governance Standard when implementing policies and procedures for comprehensive care and managing risks associated with comprehensive care. 

The patient presented for an elective temporal artery biopsy in the operating suite in a major metropolitan hospital. The patient was referred for biopsy to confirm whether prednisolone could be weaned.

The patient was administered sedation and supplemental oxygen was commenced via Hudson Mask. Surgical drapes were applied which included a wet pack to the eyes, head wrapped in drape and adhesive drape applied to the bridge of the nose, covering mouth/mask and torso creating a tent effect.

Several minutes after commencing surgery the Registrar engaged the monopolar diathermy to be used on the right side, noting a ‘flash’. The patient complained of pain and pulled off the Hudson mask, the Surgeon could smell burnt hair and stated ‘fire’.

The oxygen was turned off immediately and drapes removed revealing erythematous areas to both sides of the neck. The patient was awake and after initial treatment of burns requested surgery to continue. The patient was transferred to the ward post-operatively and discharged home the following day. Since

discharge the patient has been attending outpatient appointments with the Plastics Unit. The burns are healing with conservative management.

Although most newer diathermy machines are largely safe, the electric fields they generate are still inherently hazardous for the patient, operating surgeons, and theatre staff. They can cause burn injury, electrocution, operating room fire, smoke inhalation, and gene mutation.


  • Failure to identify risks of delivering supplemental oxygen while using monopolar diathermy on the face.

  • Failure to identify surgical draping techniques that could lead to entrapment of oxygen.

  • Failure to identify an oxidizing agent event.

  • Lack of clarity of when monopolar diathermy should be engaged, which resulted in it being engaged while not touching the tissue and causing a spark, leading to ignition of fire.


  • Prompt awareness among surgeons and anaesthetic staff regarding this avoidable hazard.

  • Nursing staff must maintain skills in diathermy and understanding of associated risks.

  • Regular education should be conducted on airway fire risk for all staff.

  • Minimise flow and inspired O2 where an ignition source is being used.

  • Improve staff awareness of open face draping to reduce entrapment of oxygen.

  • Including ‘Fire risk’ under ‘Any other risk’ on the Surgical Safety Checklist to prompt communication of fire risk during team timeout.

  • Adding bipolar diathermy as standard electrocautery device to vascular procedural packs and surgeon preference cards for temporal artery biopsies to prevent recurrence.

  • When monopolar diathermy is used it is by exception, discussed with the anaesthetist and wider team during team timeout, and used on a lower pressure setting.

  • Consider usage of a sealed airway, if appropriate.

Case 2 Serious Harm – Anaphylaxis post oxycodone administration

Standard 4 Medication Safety

4.6 Medication reconciliation  |  4.7 Adverse drug reactions

The case highlights the importance of the health service ensuring a patient’s medication history is well recorded when commencing an episode of care. This ensures that the best possible medication history and information relating to medicine allergies and adverse drug reactions are available to clinicians.

The patient was admitted from the Day Procedure Unit for an elective patella resurfacing of the right knee. Post-operatively, oxycodone was administered at three separate intervals, one in the evening, one overnight and a further dose at 0658 hours. At 0845 hours the patient demonstrated signs of respiratory compromise, shortness of breath and audible stridor. A Medical Emergency Team (MET) call was activated and the patient was given IM adrenaline, nebulised adrenaline, and puffers with symptom resolution.

During this MET call the Nurse Unit Manager became aware of an allergy to oxycodone when the patient’s personally-typed medical history, including allergies, was found in the medical record located under correspondence. The oxycodone allergy was not documented on the medication chart. 

On investigation, the patient had done this after advice from a GP when the patient was unable to recall her medical history. A further MET call was activated for return of symptoms with transfer to ICU for stabilisation and monitoring. The patient made a full recovery and did not require further advanced treatment or extended stay in hospital.


Prior to this patient’s surgery, several potential opportunities existed for clinicians to check, collect, and document adverse reaction information when commencing an episode of care.

  1. During the pre-admission process: On presentation to the specialist clinic the patient provided a list of allergies, blood type, and previous operations to administrative staff. The typed Medical History document was not read by the nurse.

  2. During completion and checking of the Health Questionnaire Form: The patient recorded only an allergy to Mefix on the form. The nurse then checked the form and following the Alerts Policy recorded the allergy to Mefix as an electronic alert on the Patient Administration System.

  3. Review by Surgical Liaison Nurse: Allergy details were not looked at by the Surgical Liaison Nurse.

  4. During the pre-anaesthetic review: When conducting the pre-anaesthetic review the Anaesthetist asked about documented allergies to codeine and Mefix but did not refer to the Alerts Form as per policy, however the Alerts Form did not contain the oxycodone allergy.

  5. Prior to administration of the first dose of oxycodone: Prior to the administration of oxycodone, the patient informed the nurse of her oxycodone allergy. The nurse noted the allergy was not listed on the medication chart; only allergies to codeine and Mefix. The patient stated the allergy was to oxycodone and believed oxycodone contained codeine. The nurse informed the patient it did not contain codeine. After this discussion the patient agreed to take oxycodone and a further two doses overnight.


  • Critical patient information is not always easily accessible due to being held in part electronic and in part hard copy.

  • Documentation of allergies was included on numerous forms which contributed to transcription errors and inaccuracies.


Case 3 Serious Harm – Lost specimen

Standard 1 Clinical Governance

1.7b The health service organisation has a risk management approach to monitor and improve adherence to policies procedures and protocols

Standard 6 Communication for Safety

6.1 Implementing policies and procedures to support effective clinical communication.

6.4b When all or part of a patient’s care is transferred within an organisation, between teams and clinicians.

6.6b The health service organisation specifies the information that should be documented about the process of correctly matching patients to their intended care.


The case highlights the importance of ensuring systems are in place for: effective and coordinated communication that supports the delivery of continuous and safe care; and maintaining the identity of the patient to ensure they receive the care intended for them.

The patient was admitted to the Operating Suite for excision and graft BCC nasal tip and biopsy nose and left nasolabial. During the procedure three specimens were scheduled for collection. 

Prior to the case starting a standard time out was undertaken, during which the consent form was reviewed and read aloud. It confirmed the three specimens to be taken. In addition, a pathology request slip was handed to the scout nurse listing the three expected specimens for the case. The form had clearly labelled items 1, 2, and 3.

After sedation was given, the local anaesthetic was infiltrated in the usual manner. Before the main procedure began, two separate minor shave biopsies were taken from the nose and the lip. These two specimens were handed directly to the scout nurse into two separate open formalin-filled pathology pots. These two specimens went to the lab uneventfully and have since been reported. The surgeon then scrubbed into the case and the BCC nose excision and skin graft procedure commenced. The BCC was handed to the scrub nurse with the suture insitu to mark the specimen. There is no information as to what happened to the specimen beyond this point. Despite clear instructions that three specimens were to be collected, only two were entered into the specimen register and collected by Histopathology. The discrepancy was not noticed, because a sign-out process was not undertaken.

Two days later the Admitting Medical Officer received the Pathology report detailing the biopsy results. It was noted the BCC nose results were missing. Staff were interviewed and remembered three specimens being collected. An extensive search of the operating room, surrounds, and formalin pot storage area was undertaken. Other pathology providers used by the facility were contacted in case of inadvertent collection of the specimen but the specimen was not found.


  • Failure to comply with the surgical safety checklist.

  • Failure to undertake sign-out process at end of procedure.

  • Failure to comply with specimen collection and handling policy.

  • Failure to comply with Australian College of Perioperative Nurses standards (ACORN).


  • Specimen collection points should be streamlined with a clear and logical process including signage.

  • Specimen labelling and handling audits should be embedded with the operating theatre environment.

  • Education on surgical safety checklist and specimen handling procedures should be ongoing.

  • Staff need to feel empowered to speak up, and have support to do so when processes are not followed.

  • Staff are required to check if ‘specimens are labelled correctly’ on a current facility form; however, ‘number of specimens’ to be collected is currently not included on any current form.

Better and fairer care. Always.

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