Safe Care Event

Posted on Mar 3, 2020 in Announcements | 0 comments

Safe Care Event

In July of 2019, a patient encountered an event that could have led to a serious safety event. Mary, 62 years old, came to the ED for a large right pleural effusion and a right chest tube was inserted. She had a known history of recurrent cholangitis due to hepatic stones and required hepatectomy (Dec 2015) to clear the bilateral intrahepatic ducts. A CT of her abdomen indicated a collection of posterior hepatic fluid and a CT guided hepatic drain was placed in IR.

The majority of the pleural effusion had drained but areas of loculation remained. Mary declined surgical decortication and consented to a trial of TPA/Dornase instilled into the right chest tube. During the sixth dose of TPA/Dornase, administered by the intensivist, the TPA/Dornase was accidently instilled in to the hepatic drain. Minutes after the incorrect drain was determined, the medication was aspirated back and 70cc of bloody fluid was collected. She endured significant pain and pressure in the region. Mary would be monitored for bleeding and worsening anemia. The following day, Mary receive a unit of PRBC.

Mary remained stable over the next few days and eventually her chest tube was discontinued. A follow- up CT indicated an increase size of perihepatic fluid collection. The hepatic drain remained in place after discharge and will have a follow-up CT in one week. She was discharged 5 days after the event.


  • IR and Nursing to label two or more drainage lines in the same region.
  • MD iInitiate Universal Protocol and Time Out process for TPA administration
  • Initiate the Sutter Safety T.R.A.C.E.R. mnemonic with new line connection or line connect

Trace existing line from the source to site
Reading existing line labels
Affix labels if/where required
Connecting compatible lines without forcing or adapting
Examining the new connection
Retracing and confirm source to site

Patrick Acebo, RN and Yenny Johnson, RN

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