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PATIENT safety bulletin Patient stories and quality of care improvement updates for residents and fellows at UCSF
MAY, 2013
Vaccination RESULTING IN vision loss CASE DETAILS:
A 19 year old male with a severe underlying immunodeficiency was given varicella vaccine as a part of health maintenance visit. Due to his immunocompromised state, he developed severe varicella retinitis, retinal necrosis, and loss of vision in one eye.
MEDICAL OUTCOME:
A prolonged hospital stay and surgical interventions were required. The patient has permanent vision loss in one eye and requires ongoing VZV suppressive therapy.
CASE REVIEW:
Record review noted unclear information regarding which vaccinations to administer. An immunology note and email did note contraindication to live vaccines, however, these communications were not prominent in the chart such that the ordering provider was aware. The patient noted that was never told of a contraindication to live vaccinations.
RCA Process:
To better understand this incident and to prevent similar events in the future, a root cause analysis (RCA) was performed. The following improvement actions have been implemented: ¥ A departmental M&M was performed, highlighting the issue and bringing attention to populations at risk from live vaccine administration. ¥ It was noted that no visitindependent place existed in the paper medical record to prominently display vaccine contraindications. APeX was configured to document live vaccines so that a pop up reminder of these contraindications appear to providers trying to order live vaccines. ¥ A drug-disease interaction alert for live vaccines and their contraindicated use in patients with an immune-compromising diagnosis was developed and is now fully functional in APeX.
From the UCSF Patient Safety Committee and Office of GME Editors: Herman S. Bagga, MD (Resident, Urology) and Mary H. McGrath, MD (Surgery and Office of GME) Questions? David Buchholz, MD (Pediatrics; Executive Medical Director, UCSF Primary Care) buchholzd@peds.ucsf.edu
Incident reports (IRs): ¥ Important, even if the situation is resolved! We want to learn from “near misses!” ¥ Allow review of adverse events and unsafe conditions to optimize processes – do not serve to punish individuals ¥ Safe, blame-free, confidential ¥ IR system may be accessed from the CareLinks Page: http://carelinks/
Root cause analyses (RCAs): ¥ In-depth, multidisciplinary review of an event ¥ Focus on systems and process improvements to prevent future events ¥ Safe, blame-free, confidential
Residents/Fellows: ¥ Play a large role in quality of care improvement at UCSF ¥ Often the first to identify patient events ¥ Can improve quality of care by filing incident reports 17