The main entrance to the hospital was enhanced by beautiful a curved pathway paved with black, shiny tiles which gleamed, and appeared nice and cool in the hot summer weather. The path was set off by the greenery of a hedge as a background. Considerable thought was given to safety precautions, including a two-layered pipe hand-railing up against the hedge, and a cement kerb on the road-side, separating the carpark area from the footpath.
This pathway leads to the main entrance, where, for the convenience of patients alighting from cars at the entrance, a holding area for wheelchairs is situated. This area is managed by the hospital security guards, who supervise the use (including signing to borrow, and checking on return), as well as assisting patients in using the wheelchair.
But only for outpatients and visitors. In the inpatient wards, each ward has several wheelchairs ready to take patients to laboratory or surgical procedures.
CSI: site inspection of the incident. Over-turned wheelchair, and cigarette butts all over the ground, as well as strewn throughout the background hedge.
The aftermath: all that is left at the scene after the patient has been taken inside the hospital for medical attention.
Re-enactment of the incident
Patient (use cartoon to protect privacy)
A 76 year-old man was an inpatient for long-term COPD problems. He was admitted on the veterans' program, had never married, and had no family in attendance. Over the years, he had had numerous hospital admissions, and now his (smoking-induced) respiratory failure rendered him so weak that he was bed-ridden for most of the time. He was able to get about by himself, but only by transferring from his hospital bed to a wheelchair, and then generally relying on the nurses to wheel him about. His arterial oxygenation was always low (from smoking and the COPD) and any small physical activity such as getting out of bed into a wheelchair usually left him quite breathless.
The patient had been a heavy smoker since his conscription time in the army as a teenager. Since hospitals in Taiwan are, by law, no longer to allow patients to smoke within the hospital precincts, this patient knew that, when he felt the urge for a cigarette, he had to go outside the hospital. From his long experience as an inpatient, he knew the places that patients and families go to for a cigarette (usually a balcony or foyer at the hospital entrances). The hospital apparently turned a blind eye to these areas as not officially being inside the hospital
§ , so tended not to bother patients using such areas to smoke.
§ At the time of the incident, there were no regulations from the department of health about whether land adjacent to hospital buildings fell under the jurisdiction, and management, of the hospital.
The patient went by himself and got a wheelchair from his ward (he did not notice that it was marked as "Broken — waiting to be sent for repairs"). He then asked a nurse to take him (in the wheelchair) to the unofficial smoking area at the right of the hospital main entrance. The nurse who took him had only recently come to work at the hospital, and after taking him to the so-called "smoking area", waited for a while, then was called back to help in the ward.
After chatting to other smokers in the vicinity for a while, the patient started dozing and his posture slackened. The cigarette he was holding fell onto his lap, and the hospital robe that he was wearing caught fire. The patient was woken by a burning sensation, and startled and flustered, he hurriedly tried to get up out of the wheelchair. The paper slippers provided by the hospital were very slippery, the footpath had recently been cleaned and waxed by the outsourced cleaning company, the sash used as a belt for his hospital robe caught in the wheel of the wheelchair.
The reason the wheelchair was waiting for repairs was because the braking mechanism had failed, so when he leaned on the arm of the wheelchair to get upright, the wheelchair went backwards from under him. The patient lost his balance, and fell headfirst into the adjacent motorbikes, resulting in a hip fracture, head concussion, and multiple bruising. There were no medical staff in the area, and no emergency button. After a period of confusion, one of the other smokers alerted nursing staff.
The hospital gown that the patient was wearing was loosely draped around his body, requiring one hand devoted to holding it in place and preventing him from becoming fully exposed (naked). The belt was merely a twisted cloth cord, which hung loosely on the ground, often getting caught in the wheels of the wheelchair, or entangling round the patient's legs when he tried to walk unassisted.
The hospital slippers were like many now used on airplanes: disposable, made of paper, and both ill-fitting and very slippery. The patient often was concentrating on keeping the slippers on his feet rather than on walking safely.
The wheelchair brake was ineffective, and the motion depicted of trying to stand would cause the wheelchair to careen backwards, leaving the patient in freefall.
The result of the incident: a patient spread-eagled on the ground with the wheelchair on top of him (after it rebounded from the fence in front of the hedge). The patient had broken bones from landing on the cement causeway between the path and the carpark. He also had head injuries from butting the parked motorcycles headfirst.
Findings from Interviews
Board Member: Was appointed to the board because of his Church affiliation, and was not involved in any way with hospital management.
Superintendent: An outstanding clinician, but no managerial experience. NHIB income continuing to decrease, and the fact that the hospital was running at a loss were his main problems. He had instituted a freeze on hiring new staff, but because of the nursing problems and increasing adverse events, had now rescinded that policy as far as nurses go; however, no one wanted to work at the hospital. Anything he thinks of doing has to be approved by the hospital board members, who tend only to look at the money involved. He feels very frustrated, and does not know what to do.
Chief of Personnel Department: The current head of the department was transferred in from another administrative department (hospital policy is to rotate staff through positions), so has no experience specifically related to human resources management. All he knows is that the hospital is running at a loss, and has decided to freeze hiring. So it does not matter what reasons departments have for applying for staff, he blocks all applications on the grounds that that is "what his orders are".
Nursing Staff: Emotions run high, and things are not good. Nurses blame each other for not doing their share, or for calling in sick and leaving others to do the work. New nurses are thrown into work without much orientation.
Chief of Nursing Department: had recently transferred to this position after retirement from a public hospital. Always comparing the current hospital negatively with where she used to work. Blames the nurses for exluding her.
Head Nurse: She is black-listed by the head of the nursing department, because of real or imagined back-biting. Consequently, unable to access hospital memoranda etc effectively. Losing interest in enforcing hospital policies.
Question: How did a patient manage to get a wheelchair all by himself?
Answer: I don't know. Because our nursing manpower is insufficient, the patient may not have the patience to wait for the nurse to pick up the wheelchair for him, so he gets out of bed and picks up the wheelchair by himself. Chronic patients are bedridden for a long time, but still have the ability to move. The distance from the hospital bed to the place where the wheelchair is placed is the range within which the patient can move, so the patient will pick up the wheelchair and use it by himself.
Head Nurse (ward where the wheelchair patient and accompanying nurse):
Question: How do you arrange the work when a new nurse comes to work at your ward?
Answer: A while ago, in the head nurses' meeting, I heard about the mentor program. They said any new nurse who came to the ward but had not yet completed the nursing orientation program should have a mentor. This particular nurse had just graduated shortly before, and although she had completed the training program for all hospital employees, she had not done the nursing orientation program. Nobody from the nursing departement told me that I had to arrange the mentor for her; besides, a few of my nurses had colds and did not come to work, so I was very busy as well as short-staffed that day. So I just said to her: please try to help out as much as you can, especially with lifting and carrying things. If you have any problems ask any of the nurses for help. I did not say who she should ask apart from this.
Question: Did you know the nurse had left the ward with the patient?
Answer: No, I didn't know.
Question: Do patients have to check with anyone if they want to leave the ward?
Answer: We have a comprehensive policy for patients leaving the hospital. If the patient wants to go home for meals or go to outside organizations for personal matters, the patient must first go the the nusing station and follow this procedure. However, there is no take leave
policy for patients moving around the hospital, because there are too many patients who would leave the ward just to move to other floors, and we could not manage them one by one. At present, patients are encouraged to verbally inform us if they want to temporarily leave the ward to go to a convenience store or other place in the hospital. No records are kept of this. If the patient is a long-term patient, and is very familiar with the hospital layout, he will, in periods of boredom, want to leave (often to go to the smoking area). In consideration of the patient's privacy, and because the hospital is not a prison, we maximize the freedom of patients and the right to self-management.
Question: Can you tell me in more detail about the wheel chair that needed repairs?
Answer: When we discovered that the braking mechanism on the wheel chair was broken, we immediately went online (to the HIS) and put in a request for it to be repaired. In theory, the engineering department will come to the ward to take the wheel chair away and repair it. Sometimes, they come imediately, sometimes it takes a long time. In this particular case, they did not come immediatly.
Question: What does the ward do with the faulty wheel chair while it is waiting to be taken away for repairs?
Answer: We put a warning sign wheel chair for repair, do not use
on the wheel chair. However, the ward space is limited and can not accommodate many such items. At present, all the wheel chairs in the ward are placed in the same corner, which is not a traffic artery. We put all the wheel chairs together and just try to put the ones to be repaired all to the same side.
Question: When a patient wants to use a wheel chair, does he go and get one himself? Or ask the nurse to help him get one? Is there a standard process for this?
Answer: In general, if the paitent is going for an examination elsewhere, the nurse first gets the wheel chair, pushes it to the patient's bedsie, and assists the patient to get into the wheel chair. Then she pushes the patient in the wheel chair to the examination room, and brings him back afterwards.
Question: How could the patient have got a wheel chair all by himself?
Answer: I don't know. Because we are so short-staffed, the patient may not have had the patience to wait for a nurse to help him, so maybe he got out of bed and walked over and got one himself. Chronic patients are not bedridden, and have the mobility to walk the short distance from his bed to where the wheel chairs are stored. So the patient could have got one himself.
Senior Nurse (the one who told the nurse taking the patient to the smoking area to hurry back):
Question: What did you say to her when the new nurse told you she was taking the patient in the wheel chair to the smoking area?
Answer: That patient was not one of mine. At that time, I was very busy because some other nurses had colds and did not turn up for work. All I could manage was to tell her to hurry back as soon as possible.
Junior Nurse (who pushed the wheelchair patient to the smoking area):
Question: Why did you accompany this patient to the smoking area? Did someone tell you to do that?
Answer: No, the patient asked me if I could help him.
Question: If you want to take a patient away from the ward, is there anyone that you have to tell first?
Answer: I have to tell one of the senior nurses in the ward.
Question: Which one did you tell?
Answer: One of the charge nurses (but not the one responsible for the patient in the wheel chair).
Question: When you told her, did this senior nurse say anything to you?
Answer: No, only to say hurry back as soon as possible.
Question: Did that senior nurse tell you anything about how to care for the patient and the things to look out for, or what things to take with you just in case?
Answer: No, she just said hurry back as soon as possible.
Question: How did you know where the smoking area was?
Answer: The patient told me where to take him. He said he often goes there to smoke.
Question: When the patient asked you for help, did you have to go and get a wheelchair for him?
Answer: No. He was already sitting in a wheel chair, and just asked me to help push.
Question: Did anyone tell you not to leave the patient's side when you take him away from the ward?
Answer: No.
Question: Did you push the patient directly to the smoking area?
Answer: Yes.
Question: How long did you stay in the smoking area yourself?
Answer: Maybe about 10 to 15 minutes, I did not see the time.
Question: What was the patient like then?
Answer: He was smoking and chatting to others. He did not talk to me specifically.
Question: Was he awake when you left? Or asleep?
Answer: He was talking to other patients.
Question: Why did you leave the patient?
Answer: Because the head nurse called the guard at the front door, and he told me that the head nurse wanted me to go back to the ward.
(The nurse who pushed the patient to the smoking area resigned two days after the incident)
Nursing Supervisor (Education):
Question: Tell me about the education and training program for a new nurse? How is it possible for a new nurse who has not completed the nursing orientation program to accompany a wheel chair patient to the smoking area?
Answer: The hospital a a one-day program for all new staff, which covers topics such as administration, salary calculations, hospitals, and emotional support. In addition, the Nursing Department has set up a nursing orientation program, but because of the number of nurses, and the lack of staff in the wards, the program is only held once a year, usually in the fourth quarter. So some nurses, having completed the general orientation program run by the personnel department, are immediatly seconded to a clinical ward, where they start working until their turn comes to attend the nursing orientation program. Although the nurse who took the patient to the smoking area had joined the hospital in the latter part of the year, she had not yet attended the nursing orientation program.
Question: Isn't this a contradiction? New nurses have not completed nursing orientation, but are being asked to act as nurses in the wards and care for patients?
Answer: Yes, this method is really not ideal, but because we have so many new nurses, this is our current arrangement. However, in practice, we have a system of senior nurses who act as mentors to the new nurses until they attend the nursing orientation course.
Question: Does the new nurse who took the patient to the smoking area have a mentor?
Answer: Because we assigned the nurse to that ward, it would be the head nurse for that ward who would designate a senior nurse to be the mentor.
Nursing Supervisor (in charge of Quality Management):
Question: How do you monitor the quality of care in this ward (where the patient had the wheel chair fall)? Do you have any information about this particular incident?
Answer: The ward is a respiratory care unit. We meet all the equipment and accreditation standards. The quality indicators being monitored for this ward are also in place to meet accreditation requirements. They are mostly APACHE II and frequency of re-admission indicators. Only after this incident happened were we notified, and we started to investigate any parts of the nursing care plan that were not being implemented.
Logistics Department (manager responsible for overseeing outsourcing to cleaning company):
Question: Please describe the current situation in regards to outsourcing to the cleaning company,
Answer: The cleaning staff are responsible for all the hospital walkways, regularly cleaning the floor in the rooms, and waxing afterwards. The current practice is to conduct monthly checks on the cleaning results and use the results to give feedback to the company about whether they are meeting conditions listed in their contract. In addition, there are items such as SDS-related supplies and usage procedures, such as toxic cleaning agents, that need to be handled safely. We use spot checks to monitor compliance with these standards.
Question: On the day of the incident, did your department instruct the cleaning company to clean and was the pathway?
Answer: On that day, we gave no special instructions. The cleaning company judged that as the hospital facade, it needed cleaning and waxing, and went ahead with that. We did not know that they did that.
Manager for Cleaning Company (outsourced):
Question: Is the hospital monitoring the way your company does the cleaning business?
Answer: The hospital has a strict contract system, which lists the standards required for what should be implemented, and also what should not be done. The terms of default are clearly stated with numeric penalties listed for each class of error.
Question: Is there any training provided to your staff about the risks of SDS cleaning products?
Answer: The company currently provides staff education and training, but because of the high turnover of staff and lack of time, it is difficult to fully implement it. The hospital also requires education and training. So our company does not specifically plan to do education or training.
Question: Why was the pathway outside the hospital waxed after it was washed? What were the conditions of the job on the day the incident happened?
Answer: I was not there on the day of the incident, but I heard the cleaning staff say that, because the fall happend outside the hospital, but the hospital was insisting on beautification, they were obliged to perform cleaning and waxing. However that area has no roof, and it was raining that day. My staff waiting for lulls in the rain to use electric fans to speed up drying the surface, then completed the cleaning and waxing. Although they did the right thing, but it is difficult to say when working outdoors. No one from the hospital told my staff not to was, so it has been the routing ever since they have been doing it.
Engineering Department (chief):
Question: Is there a process in place for management of wheel chair maintenance? If a wheel chair is damaged, say, for example, there is a problem with the braking function as in this incident, is there a management solution for this in place?
Answer: Yes. Every wrd can access the hospital information system (HIS) and make an online request for wheel chair maintenance. The HIS immediately prints out at our end the request as soon as it is entered into the system. My staff will action the request immediately, by going to the place where the faulty item is, and transporting it to our department in the Basement Level 1. There the item is put in the holding area, to wait for repairs.
Question: So there is no opportunity for patients in the wards to be able to borrow a faulty wheel chair?
Answer: We deal with every request for repairs as soon as it arrives, so there are no faulty wheel chairs in the wards.
Engineering Department (staff):
Question: Please explain the process where requests for repairs to equipment come through and are printed out on the printer in your department.
Answer: After a ward completes the online form, the request is printed out immediately at our end. We immediately review the contents of the request, then go and collect the item (wheel chair) for repair and bring it back down here to Basement Level 1, where it is put in the designated area to wait until it can be repaired. However, sometimes we are busy and do not notice the printout, or are unable to deal with it immediately, so you stick the ticket on the noticeboard and wait for a few other similar applications. After that, you tend to deal with them together. Because of our limited manpower, and the fact that now we need to go to support a branch hospital, our actual available manpower is not as much as shows up in personnel registries, especially at night or on weekends.
Question: So the wheel chairs needing repairs have been put in the system, but they may not be immediatly retrieved from the ward and brought back to your department?
Answer: Yes.
Question: Are you involved in advising the wards on how to handle the items that are waiting for repair but are still in the ward?
Answer: No. We only process the invoice to the relevant ward, and are not involved in any other interaction with the ward staff.
Respiratory Therapist:
Question: The patient who had the fall was an inpatient in the chronic obstructive pulmonary disease (COPD) ward. Do you treat patients in that ward?
Answer: We have a respiratory treatment team; all of them are respiratory therapists.
The supervisor is a specialist in chest medicine.
Our main job is to treat patients in intensive care units who are on ventilators. We also provide respiratory therapy in other wards. However, because of our limited manpower, services to wards is restricted to day shifts, and we do not cover them at night. Nurses in each ward take over during the night shifts.
Question: How do you hand-over to the nurses and coordinate respiratory therapy?
Answer: Currently, we do not hand-over to nurses. Our work shift is from 8:00 am to 5:30 pm; the nurses work three shifts, and have different hand-over periods. Therefore, there is no special "hand-over" process, and we work separately from them.
Question: Does the respiratory therapy team, or you yourself, give the nurses any training on how to take care of patients with respiratory problems?
Answer: Occasionally, the nursing department will make an invitation. Our team leader will give a lecture, maybe once a year. However, I do not know the exact time or frequency.
Other patients in the smoking area:
Question: Did any of you see the patient fall? How did it happen?
Patient A: I saw a young nurse push him in. She did not stay long. After that, I talked to the people next to me and did not pay any attention to him.
Patient B: I saw him come in and the nurse quickly left. I saw that he was breathing hard when he was smoking. Then it looked like he fell asleep. He did not speak to me.
Patient C: I did not see him come in because he was already here when I came. But when he was asleep, I could see the red of the cigarette in his mouth, flickering as though he was still smoking while asleep.
Engineering Department (responsible for environment works = landscaping):
Question: Why replace the tiles in the smoking area?
Answer: Hospital accreditation emphasizes that the environment should be neat and beautiful. Therefore, the high-level executive ordered that the floor tiles should be completely replaced and the hospital upgraded to maintain an overall beautiful exterior. The update project included replacing the outside concrete floor tiles with tiles recommended by the interior design consultant. Their recommendation was for these black, glossy tiles.
Question: Has anyone complained that the tiles are slippery? Or is the situation that if the executive orders it, you must do it, without the need to ask the views of relevant departments about risk and related issues?
Answer: No one complained to us. When the executive orders it, he expects it to be done by "yesterday", so in accordance with his instructions, we planned and executed the project as one of our department's jobs.
Question: Is the smoking area part of the hospital precinct? There is a roof over the main entrance where patients get in and out of cars, but none over the pathway (smoking area), is that right?
Answer: No, the smoking area does not belong to the hospital precinct [Later the laws were changed relating to how much space outside the hospital wall belongs to the hospital precinct] That area (pathway used as a smoking area) is open-air. We only carried out the walkway beautification and installed a simple fence on the hospital side to prevent someone from falling into the bushes.
Logistics Department (responsible for patient clothing):
Question: Was there any problem with the clothes that the patient was wearing at the time of the incident?
Answer: The clothes were standard. We have a very strict management system for patient clothing, included detailed checks to see if items need to be replaced or eliminated. Aftr this incident, we checked all our inventory, and also the actual items that the patient was wearing, and found no defects; they all met the standards of hospital procurement. There may be problems arising from the patient's personal habits in regards to wearing clothes; for example, some people are not accustomed to being neatly dressed, with the cord serving as a belt used to bind the robe firmly around the body. Consequently, the cord may loosen and get tangled in the patient's legs or his wheel chair. The hospital slippers may not match the patient's feet, since the slippers are all one size, but patient's may be overweight, tall, or foreign. Consequently, the slippers can be ill-fitting, and contribute to affecting the patient when he tries to stand or walk.
Rehabilitation Department：
Question: If the engineering department wants to add rooms or modify the environment (e.g. paths), do they have to consult your department first, to discuss risk and related issues?
Answer: Currently no one consults us on such issues.
Infection Control Department：
Question: If the engineering department wants to add rooms or modify the environment (e.g. paths), do they have to consult your department first, to discuss risk and related issues?
Answer: Currently no one consults us on such issues.
Security Personnel at hospital main entrance (guards):
Question: There are many wheel chairs near the hospital entrance. Is your unit responsible for the management of these wheel chairs?.
Answer: Yes, our wheel chair program has an excellent management design. The pedals on older models may easily cause falls, and most people tend to lean back and fall when they are not paying attention to the wheel chair; therefore, our hospitals has wheel chairs specially made to overcome these faults. In addition, each wheel chair has a unique property code and RFID, so that when someone borrows a wheel chair, we swipe their health card and then swipe the wheel chair ID so we know who borrowed it and when. Any wheel chair can be returned at any of several entrances and exits. When the wheel chair is returned, the system automatically reads which wheel chair and who borrowed it into system management software. The wheel chairs that we manage are for outpatient or emergency room patients and their families.
Wheel chairs are available in some inpatient wards, where they are used to transfer patients to radiology and other examinations, or to take the patient to other areas of the hospital. However, they are managed by the wards and not by us, so I am not sure how their system works.
Question: The smoking area used by the patients is almost always in the vicinity of the hospital. Is there a surveillance system (CCTV) installed in the hospital to monitor the smoking area? Is it possible to see a recording of the actual incident, and identify the time frame of how it happened?
Answer: Originally, we did not monitor that area because it is not part of the hospital; however, we have very good relations with the local police station, and they asked us to install an outwood-directed camera; but this was to monitor accidents at the nearby cross-roads. Because of the angle, the smoking area is not included in that camera's scope. So there is no way to provide video of the incident.
Incident Reporting System (IRS) Personnel:
Question: Have there ever been reports of falls in that area before?
Answer: No, it never happened before. But over the past six months, we actually did receive two reports: one was a nurse coming to work at midday; the other was a young mother going home at night after visiting a relative who is an inpatient at our hospital.
Question: Was it raining at the time?
Answer: Yes, it was raining that night when the young mother was leaving after visiting hours were over. But not the other time. The nurse was walking in broad daylight; the sun was shining brightly.
Question: So, what was the result of your investigations at that time?
Answer: Well, since that area is outside the hospital limits, we cancelled the incident report, which is for reporting incidents that occur within the hospital to hospital patients, and did not do anything further.
Question: But what about the people who fell?
Answer: Oh, they were just treated by our emergency department as usual.
Hospital environment
At the time of the incident, in accordance with the Department of Health guidelines, the hospital made public announcements that smoking was not permitted within the hospital and attempted to monitor compliance of patients and staff within the precints. However, cigarette butts were often found in the stairwells, and even patients surreptiously sneaking a puff there.
Also at the time of the incident, no one was responsible (or designated as the manager responsible) for the areas outside the hospital, abutting the hospital walls (such as the walkway and hedge area where the patients were chatting and smoking).
However, by the time of the RCA investigation, national laws had been passed that made hospitals responsible for a set distance limit outside the hospital walls; this made the rules about no smoking within hospital
applicable to the area where the wheelchair incident in question occurred!