PRACTICE PARTNER
PATIENT SAFETY
We use this forum to regularly report on findings from patient safety organizations, expert review
committees of the Office of the Chief Coroner, and inquests.
T
he death of a middle-aged man,
who was receiving vancomycin
administration and monitoring
at home, has raised concerns re-
garding the level of communication among
health-care practitioners.
“Care in the community is complex and
requires clear communication protocols,
including roles and responsibilities of the
various care providers,” stated a review con-
ducted by the Patient Safety Review Com-
mittee (PSRC), an expert committee of the
Chief Coroner’s office.
It has become common to administer in-
travenous antibiotics and other medications
in the community. Certain medications
however, require additional safeguards.
These safeguards should be clearly estab-
lished before administration of the medica-
40
DIALOGUE ISSUE 4, 2018
tions can be undertaken in the community.
The 54-year-old man had developed a dia-
betic foot infection in the summer of 2013.
On July 15, 2013, the patient was admitted
urgently to Hospital A. He was treated with
vancomycin, ciprofloxacin and metronida-
zole intravenously (IV).
On July 23, he was discharged to home
care with orders for IV vancomycin and
oral ciprofloxacin, metronidazole and
fluconazole. On the day of discharge, he
communicated with the Community Care
Access Centre (CCAC) indicating that he
was feeling unwell, was no longer able to
walk with his cane and needed a walker.
On July 25, he contacted CCAC with
concerns about swelling of his feet. On July
27, (four days after discharge), he devel-
oped a rash and returned to the emergency
Some Medications
Taken at Home
Require Additional
Safeguards