In late 2019, a patient at Mercy Hospital for Women (MHW) was left with a permanent stain on her arm following an iron infusion – something that can happen in that procedure, but which had not been explained to the patient. Thanks to the patient’s willingness to speak up about her experience, Mercy Health has now changed the process around iron infusions to make the communication and consent process clearer for everyone involved. While the error in this patient’s case cannot be undone, it is our ability to listen to patients and learn from adverse events that enables us to continue improving our care and services.
Ms A was a patient at Mercy Hospital for Women (MHW) and received an iron infusion following the birth of her baby. The iron infusion resulted in Ms A being left with a 10cm by 10cm permanent stain on her arm.
Ms A contacted MHW to give feedback that if she had known about the potential adverse outcome, she would have declined to have the procedure. After an investigation, it was noted that a doctor prescribed the infusion and a nurse then organised the infusion. The nurse verbally informed Ms A of possible symptoms, which included feeling nauseous, experiencing pain at the intravenous (IV) tube insertion site or having a metal taste in her mouth.
Ms A was advised to let the nurse know if she experienced any of the symptoms and the infusion would be stopped. Ms A was also advised that sometimes iron can drip from the IV tube and if this happens that it can drip onto skin or clothing and cause a stain. Ms A advised that iron did drip from the IV tube onto her clothing, which she did not mind. The nurse was competent and monitored the infusion throughout the process. The nurse advised that she had not seen an iron infusion stain before and feels confident that she would have escalated and documented as required if she noticed staining at the time.
The following day, Ms A was advised that she could be discharged home. She noted that she had significant bruising of her arm but was told that can happen and should heal within a couple of weeks.
Three months later, Ms A had an appointment with her GP as the bruising had not faded. She also noted that she had been experiencing pain throughout her arm and the site was sore to touch. Ms A’s GP suspected that her iron infusion had permanently stained her skin and referred her for further medical follow up which confirmed this.
Ms A subsequently submitted feedback regarding her experience. An investigation revealed that while Mercy Health has a patient information sheet available that includes information about permanent skin staining as an adverse effect, it is not documented that this information was shared with Ms A. At the time of Ms A’s iron infusion, there was no formal consent process for iron infusions. As a result of Ms A sharing her experience, the consent process for iron infusions has been reviewed and the iron infusion prescription form has been updated. The form now includes a section for staff to obtain patient consent and the patient information sheet is attached, which outlines the possible risks, including permanent skin staining.
While Mercy Health was regrettably unable to change Ms A’s experience, we are grateful that Ms A’s feedback lead to an improvement in the process for a better patient experience.
Care first: Quality Account 2019/20
Last reviewed March 10, 2021.