Safety incident: sharing learning

The Non-Hospital Medical and Surgical Facilities Program Patient Safety Incident Review Panel recently reviewed an incident of pneumothorax following fine wire localized partial mastectomy and sentinel lymph node biopsy. In the post-anesthesia care unit, the patient had persistent issues with low oxygen saturations and ongoing chest pain.

Contributing factors to this incident included not documenting a respiratory exam, which raises concerns that: one was not performed and that the persistence of chest pain and decreased oxygen saturation did not trigger further assessment and follow-up investigation; and that it was assumed the pain was incisional without considering alternative causes.

Following its review of this patient safety incident, the panel recommended that:

  • pneumothorax should be considered as a differential diagnosis when the post-operative stay, following use of fine wire guidance in the chest area, is complicated by chest pain and oxygen desaturation
  • education should be provided to staff regarding this possible complication with a reminder of the importance of continuous assessment and examination with proper documentation

This information and recommendations are being shared with all facilities in the spirit of learning and improving patient safety. Medical directors are encouraged to discuss this article with their clinical teams.