INCIDENT REPORT

To be completed by staff within 12 hours of incident/accident

Nature of Incident

Clinical Incident ☒ Non-Clinical Incident ☐ Near Miss ☐

Details of Patient/Injured Person (If applicable)

PRN 01-20-00399 Patient’s Name Bun Kong Soung

Gender ☒M ☐F Date of Birth: (15/12/1975) Age 45

Incident Details

Exact Location: CT Scan Room

Incident Date: 27/11/2020 Incident Time: 09:40 - 10:10 am
(SGMC)
Department: Radiology Service Area: CT Scan Ward (if appliable):
Narrative Report:
Doctor Su Lin has requested CT Scan of the Abdomen with contrast media to patient named Bun
Kong Soung. Doctor noted that patient has GERD (Gastroesophageal reflux disease) and still having the
Reflux symptom.

On that day Mr Bun Kong was handled by Gale, he discussed with the patient the examination that
has to be done, the preliminary precautions like the adverse reaction of contrast media, asked the
patient for his history of allergy and let the patient sign on the Declaration Form and Gale took the
patient's vital signs. All are normal.

On my part, beforehand I look into all the requirements which are essentials before the examination
When it's all complete Nurse Lydia perfectly placed the cannula. Patient started to drink water with
a contrast media (4 bottles of 350ml water with the mixture of 10cc dye). Mr Bun Kong felt dizzy
when he had drunk about 1050 ml of liquids we immediately call the attention of Dr Su Lin and the
nurses. Initially I ask the patient when is his last meal, any history of hypertension and if it's his first
time to do CT Scan as I had experienced from my former patients' that some of these factors are
the reasons why the patient experience dizziness and I found out that patient was over fasting
basically, these would be one of the factor of feeling faint or unsteady and also having high blood
pressure. Nurse check the blood pressure on the spot and we assisted patient going to Dr Su Lin's
consultation room so Mr Bun Kong can rest, about 10 minutes later patient insist to proceed the
examination with the consent of Dr Su Lin. Promptly I positioned Mr Bun Kong to the CT Scan table
and asked patient well-being and I received a positive response. Gale scanned for the plain scan
after this I asked the patient again on how he felt and explained the adverse reaction of contrast
media and discussed what he might feel during and after the injection of dye. I informed him for the
test dose (5cc of contrast media) and let him know that we will wait 5 minutes before injecting the
full dose. After 5 minutes I asked Mr Bun Kong how is he and I have review to him once again the
adverse reaction and the things he might feel, taste and I gave him assurance that anything he
might feel discomfort he should inform us right away I told him that we are the next door and if he
will speak we can hear him. As what I had noticed patient was a bit uneasy so I decided to give the
full dose manually with the help of injector. While giving the contrast media I am explaining to Mr
Bun Kong what I am giving and when I am almost done I injected 75cc of dye he mentioned that he
has difficulty of breathing therefore, Gale directly called Dr Su Lin. And while waiting for Dr, I talked
to Mr Bun Kong ask how he feel and informed him that I am injecting the saline, explaining that it is
water and why I injected it to him.

Doctor arrived quickly and do auscultation to the patient however, from what we observed she had
shown the behaviour who was in panicked and seem like perplexed. She even shouted on us while
the patient is present with fully conscious mind, not knowing that the behaviour that she manifested
might be used against the reputation of the Center and its employee. Nonetheless, I tried to ask her
if we could do the last scan as I assess the patient’s consciousness I feel like we can manage to do
it but Doctor refused it and we respect that. I told Gale to stop meaning to abort the procedure but
we never scan when Doctor arrived. There and then I move out the patient on the CT Scan table.
While doing that Dr never stop to grumble and she asked what she needs like getting the blood
pressure and transporting the patient to the room because she said she cannot do anything in the
CT Scan room. On the other hand, patient compared the Center in Thailand, where he mentioned
that he never experienced this. Mr Bun Kong seems to be agitated luckily at this point Dr Su Lin
was able to explained the situation. With the help of Nurses Mr Bun Kong was successfully
transferred to room 8. As a Radiographer our task will end there, we advised them if the patient
is stable try to convince to undergo one more scan of his abdomen fortunately, Dr and Nurses team
was good on convincing the patient hence we accomplished to do another scan even though our
images was not in great quality.

Incident Cause:
1. Adverse Reaction of contrast media.
2. Lack of preparation resulting to panic and anxiety.

Action(s):
1. Revising the protocols of each examination with contrast media administration.
2. Prepare in advance the emergency kit.
3. A Doctor and a Nurse must be present for all CT scan with contrast examination.
4. Review on how to facilitate the first aid.
5. Improve the action to be done when emergency cases occur.
6. BLS and first aid training.

Completed By: Benign Ellimann De Oño Designation: Radiographer Report Date: 04/12/2020
Staff Involved in Error: Doctor Su Lin, Gale and Designation: Doctor and
I. Radiographer