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Posted on 19 Apr 2022
Incident response/review

Adverse patient safety events are rarely isolated to one health service and much can be learned by sharing review findings. 

We will provide regular snapshots of sentinel events notified to Safer Care Victoria. We will unpack identified contributing factors and, most importantly, share the work being done within health services to address the review findings and prevent similar patient harm from occurring in the future.   

This sentinel event lesson relates to clinical deterioration following the administration of oral sodium phosphate solution. 

Situation

An 81-year-old surgical patient developed a pseudo bowel obstruction on day five post their total hip replacement, which was treated with multiple doses of oral sodium phosphate solution (Fleet Phospho-Soda).  

The treating clinicians were unaware of the risk of electrolyte imbalance with this medication, particularly in an elderly patient. As a result, the patient developed hyperphosphataemia, which was not recognised or treated, and subsequently suffered a cardiac arrest and died. 

Family involvement in the review 

The family was informed that a review was being undertaken and was invited to provide their questions or feedback for consideration by the panel.  The family asked three questions, all related to the clinical care of their loved one. Two questions were specific to the bowel obstruction management, which was not in line with best practice and helped to identify this as a critical event in the review. The family was provided with a summary of the review outcomes, including responses to the questions asked, and the subsequent findings and recommendations. 

Health service actions 

The review team recommended that oral sodium phosphate solution no longer be used for any patient across the organisation and developed a best practice guideline to safely manage bowel obstructions within the health service. The health service also reported this event to the Therapeutic Goods Administration (TGA) and flagged the case with SCV, requesting a state-wide alert in relation to oral sodium phosphate solution be considered. 

Lessons  

Prescribers should be aware that sodium phosphate laxatives can cause serious fluid and electrolyte disturbance, including hypocalcaemia, hyperphosphataemia and hypokalaemia. Acute renal failure, cardiac arrest and deaths have been reported.  Use of the oral product is contraindicated in the treatment of intestinal obstruction.  

Given the potential for complications, the use of oral sodium phosphate solution should be avoided in elderly patients.  Oral sodium phosphate solution should be used with caution in those under 18 years of age, people with kidney or heart disease, people who are dehydrated or have hypercalcaemia, and those taking drugs that affect renal perfusion and function (e.g. angiotensin converting enzyme [ACE] inhibitors, diuretics, angiotensin II receptor blockers, nonsteroidal anti-inflammatory drugs [NSAIDs]). 

This case also highlights the importance of early engagement with affected patients and families during the review process, and how this not only improves consumer relationships, but also health outcomes.

Page last updated: 19 Apr 2022