CLINICAL INCIDENT REPORT

QMD-03-004-00
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STRICTLY CONFIDENTIAL UNAUTHORIZED REPRODUCTION OF THIS DOCUMENT IS STRICTLY

PROHIBITED
REPORTING PARTY REQUESTED CONFIDENTIALITY?

INCIDENT NOTIFICATION

YES

NO

(to be completed by Department Quality Circle/investigating body)

SUBJECT DETAILS
LAST NAME

FIRST NAME

Sze

Yeung Ping

RECORD/PATIENT NO:

UNIT

181900

5 MAIN

DATE OF BIRTH

AGE

SEX

12.13.40

83

Male

PATIENT

VISITOR

PLACE OF INCIDENT

EMPLOYEE

OTHER:

(Where did the incident occur?)

UNIT E.G. RADIOLOGY DEPT./6TH FLOOR

SPECIFIC LOCATION E.G. BATHROOM, X-RAY ROOM

DATE OF INCIDENT (MM/DD/YR):

TIME OF INCIDENT:

August 8,2013

3:00PM

DEPARTMENT OF SPECIALTY

Medicine
INCIDENT INVESTIGATION AND ANALYSIS
(to be completed by Department Quality Circle/investigating body)

DESCRIBE THE ACTUAL OR POTENTIAL INCIDENT:

Please include the immediate response and outcome. For medication incidents please state all drugs involved. (Please attach an extra sheet of paper if
needed).

That on August 7,2013 at around 10:20PM Dr. Peter Sy ordered Peptamen 5 scoops in 180 cc water every 4
hours as drip for patient 507 Sze Yeung Ping.
The bedside nurse on that shift (CB shift 6PM-6AM) Benedict Mecija was the one who started and prepared
the Peptamen fomula.Nurse Benedict fixed the Peptamen formula at 4AM, Nurse Benedict rinsed the
calibrated glass and spoon using the patient's own bottled water but the relative made another cleaning of
the glass & spoon using warm water, Nurse Benedict & the relative cleaned the surface where the
peptamen will be prepared, with mask & gloves on during the entire preparation. Nurse Benedict opened
the new can of Peptamen and mixed it with 180 ml of bottled water.He also checked for the patency of the
Kangaroo bag and its tubing before he put the Peptamen Formula in the Kangaroo bag then he primed the
milk and connect it to the gastrostomy tube. Nurse Benedict stay for the patient for 15 minutes for
regulation and observation of the feeding.
That on August 8,2013 CA shift (6AM-6PM) nurse Emmanuel Colipano was the assigned bedside nurse to
the patient.At 7:30AM Emman was due to prepare his Peptamen Feeding.But before doing that Emman
assess the gastrostomy tube of the patient.Then Emman started to prepare the Pepatmen Formula, the
patient's wife was the one who washed the calibrated glass used for mixing the Peptamen Formula, with
mask & gloves on nurse Emman combine the water & Peptamen and he make a thorough assessment on
the kangaroo bag , cheked for any leak and he saw nothing except for the lumps of undiluted milk powder
from previous feeding, the patient's wife was beside nurse Emman all through out the preparation of the
Pepatmen Formula and until he poured it to the Kangaroo Bag.Then at around past 1PM the relative noticed
a dot black particle on the bag of Peptamen Formula then nurse Emman informed me.

DO NOT PUT THIS FORM INTO MEDICAL RECORD

CLINICAL INCIDENT REPORT

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CONTRIBUTING FACTORS
Please include any factors contributing to the incident including: Staff factors e.g. fatigue, skill/knowledge deficit, failure to follow policy, communication
problem. Subject factors e.g. mental condition, social support, aggression, inadequately medicated, over stimulated environment, failure to follow
instructions. System factors e.g. access to services, lack of training/policy/facilities. Consider anything that occurred immediately before the incident.

water
Peptamen Formula
Kangraroo bag
nurse who prepare the Peptamen

TREATMENT/INVESTIGATIONS ORDERED
E.g. X-ray, Blood test, ECG, EEG, Dressings, New medications, Referral for review by another clinician.

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CLINICAL INCIDENT REPORT

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WHAT FACTORS MINIMIZED THE OUTCOME?

E.g. early detection by monitor or alarm. Good assistance, Good plan or
protocol, Consultation or conciliation, do-escalation techniques, use of
PRN medication.

HOW COULD THE INCIDENT HAVE BEEN PREVENTED?

E.g. Equipment checks before use, better written or verbal communication,
and better work lay-out/teamwork.

The kangaroo bag should be change every feeding of

the patient.

MEDICAL PRACTITIONERS EXAMINATION OF SUBJECT

Name:

Date:

/ /

Time:

INCIDENT INVESTIGATION AND ANALYSIS

SENIOR STAFF EVALUATION
To allow for full evaluation of the incident, please ensure that all results are available e.g. blood test, X-rays etc.
Describe results of investigation and findings. Please do not repeat a description of the incident

The small black dot that the relative noticed and claimed as " insect " was immediately coordinated with
the warehouse supervisor Ms. Anna beacuase I doubt that it was an insect and best described as carbon
paper, but if you were going to closely check and feel it, it can be best described as like rubber thing.
The kangaroo bag with the small black dot together with the milk from the bag was sent to warehouse for
investigation care of the supplier. Ms. Anna coordinated with the supplier.
That on Monday August 12,2013 at around 9AM the milk was sent to laboratory for culture to check for any
bacteria that contaminated the Peptamen Formula.
That on Wednesday August 14,2013 around 2PM the result of milk culture was released as
ACINETOBACTER BAUMANII - VERY LIGHT GROWTH.I inquired to the senior MedTech Ms. Maria Criselda Del
Rosario about the bacteria and where it came from, she told me that ACENITOBACTER BAUMANII possibly
came from environment & handling of the milk. I informed Dr Peter Sy about it.
That on Thursday August 15,2013 Dr Peter Sy told me that he informed the patient's wife about the very
light growth of bacteria found in the milk culture.
To further explore the ANICETOBACTER BAUMANII, I asked the Infection Control Ms. Rhoda Gayco about the
said bacteria and she told me that possible sources of it were the water,the kangaroo bag, milk (peptamen
formula) and the nurse who prepares it. ANICETOBACTER BAUMANII is a water organism and isolated from
hospital environment & hospitalized patient.
My analysis about the ANICETOBACTER BAUMANII found in the milk culture could be from the water since
the bacteria is a water organism.

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CLINICAL INCIDENT REPORT

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Name:

Alona D. Alfaro,RN

Designation:

Signature:

Charge Nurse

Date &Time:

August 15,2013

THIRD PARTY COMMENTS

Please forward this form to any relevant 3rd party area for comments e.g. Pharmacy, Radiology, Laboratory, etc.

Name:

Designation:

Signature:

Date &Time:

DEPARTMENT/SERVICE HEAD OR DIRECTOR COMMENTS

Comment on action taken or needed to prevent recurrence. Comment on resource implications. Please do not repeat the senior staff evaluation.

Did the incident result in an increase of costs or length of stay, or consume extra resources? Please specify:

No it did not increase any costs to the patient. The patient was discharged on December 2, 2012

Name:

Ms. Delia C. Ramos, CCRN, MAN

Designation:

Nursing Division Head

Signature:
Date &Time:

DO NOT PUT THIS FORM INTO MEDICAL RECORD