Case Study: Can You Prevent This Medical Error?

SafetyNurse1968, ADN, BSN, MSN, PhD

CASE STUDY

Ms. Grant (not her real name), a 68-year-old woman, recent cardiac bypass

Postoperative for elective cardiac bypass with significant complications: ventilator acquired pneumonia, right-hemispheric stroke, clinically significant GI bleeding, acute tubular necrosis requiring hemodialysis

Stated on the morning of the event: "I feel good for the first time in a long time."

Morning of a planned transfer to step-down patient was observed coughing and moving head and extremities in an uncontrolled manner. BP 220/95 mmHg.

No history of seizure or seizure medications

Blood was drawn, the patient was taken for a CT to rule out a stroke or cerebral hemorrhage

Serum glucose came back 0 during transport to CT lab

The patient died after being in a coma on life support for 7 weeks.

What happened here? A woman well on her way to recovery from a difficult postoperative course was about to be transferred from the ICU to a step-down unit. What caused the seizures? Keep reading to find out (Link to full article is at the end of this blog post)1.

MEDICAL ERROR

The Institute of Medicine published a report in 2000 called "To Err is Human"2. This report is based on thousands of chart reviews from various hospitals in the late 80"s and 90's. Americans were shocked to find out that medical error kills the same number of people as if a jumbo jet full of passengers crashed every week, with no survivors - approximately 44,000-98,000 deaths per year. These numbers are likely a gross underestimate, with the true number being closer to 400,000 deaths per year.3Recent research suggests medical error is the third leading cause of death in the US. In a report from the British Journal of Medicine in 2016, the authors analyze how medical error fits in with the leading causes of death (heart disease and cancer are still 1 & 2) with lower respiratory disease being 3rd and accident 4th.⁴

I think it's safe to say that almost no one in healthcare wants to make an error. Despite our best efforts, we continue to harm patients (I talk about this in another blog post. This list shows the most common medical errors.

MEDICAL ERRORS

Adverse Drug Events6
Catheter-Associated Urinary Tract Infection
Central Line-Associated Blood Stream Infection
Injury from falls and immobility
Obstetrics
Pressure ulcers
Surgical site infections
Venous thrombosis
Ventilator-Associated Pneumonia

The National Patient Safety Foundation has a Vision Statement: Creating a world where patients and those who care for them are free from harm.5 We can also most likely agree that our goal is for patients to be free of harm - specifically preventable accidental harm. We cannot eradicate human error, but we can build safeguards where we know error is likely, thereby decreasing the impact of errors and potential for harm.

TIMELINE

Back to the case study. Have you come up with some ideas for what happened to Ms. Grant? Take a look at this time line from the actual incident to give you some additional information.

Time	Event
0430	Nurse draws blood for routine morning laboratory tests: serum glucose level is 6.72 mmol/L (121 mg/dL)
0600	Medical student visits patient before team rounds. Patient is stable
0610	Cardiothoracic ICU team visits; no new issues are noted. Patient is showing much improvement; team has every expectation that she will make a complete recovery
0620	Patient drinks small amount of orange juice; note in chart indicates patient is stable
0635	Nurses uses a straight urinary catheter to drain a patient's bladder per standing order. Patient appears well by tired; expresses a desire to nap.
0645	The alarm goes off, alerting nurse to occlusion of the patient arterial line; nurse flushed line with 2 mL of heparin lock flush.
0735	Day nurse receives shift change report from night nurse and assumes care of the patient.
0745	Night nurse completes shift. Patient is reported to be sleeping soundly
0815	Day nurse discovers a patient having seizure activity. Labetalol is given by day nurse for systolic BP >200 mm Hg. Patient physician is called.
0820	1 mg lorazepam given IV by the nurse for an apparent seizure
0835	Neurology is called for an abrupt change in LOC
0842	Emergent CT whos no evidence of intracranial hemorrhage, mass or mass effect. Lab notifies ICU that serum glucose is undetectable. 1 ampule 50% dextrose in water given IV
0855	1 mg lorazepam IV
0905	1 mg midazolam given IV push, patient intubated

Where in this time like could an error have occurred that cause Ms. Grant's death? I want to emphasize that she didn't die from any of her multiple post-operative complications. Ms. Grant died as a direct result of an unintended, preventable medical error that occurred between 0430 and 0815.

Here is the rest of the timeline, and the piece of information that will most likely lead you to the most obvious cause of her seizure.

0915	Day nurse discovers bottle of regular human insulin on medication cart immediately outside patient room
0920	1 mg midazolam IV push
0945	10 mg chlorpromazine, 6 mg morphine, 2 mg midazolam IV push
0950	1 ampule 50% dextrose in water given
1005	Glucose level of 1.3 mmol/dL (24 mg/dL) reported from lab
1015	1 ampule 50% dextrose in water given
1100	2 ampules 50% dextrose in water given
1245	5 mg labetalol given IV push for systolic BP of 195 mmHg
1315	1 ampule 50% dextrose in water given for serum glucose of 3.1 mmol/L (55 mg/dL)
Remainder	Blood glucose level difficult to maintain, patient comatose

After a thorough investigation of this sentinel event, it was discovered that at 0645, the nurse flushed the patient arterial line with insulin instead of heparin. Due to the presence of insulin on the medication cart, there is no way to determine if this was the first time this had happened.

NURSING ROLE

I'm teaching the fundamentals of nursing right now to brand new BSN nursing students. What follows is a description of what we teach them. The nursing role is to administer medication as prescribed while preventing error and patient harm.

What goes into "administering medication as prescribed"? In addition to being aware of federal, state, and institutional regulations, nurses also need to know the nurse practice act and their scope of practice.

NURSE KNOWLEDGE OF MEDICATIONS:

Generic- given by the original manufacturer which becomes the drugs official name, vs. Trade- name under which the drug is marketed.
Look-alike/sound-alike drugs- list produced by the Institute for Safe Medication Practices and the Joint Commission.
Classification- indicates the effect of the drug on the body/site of action.
Medication Form- the form the medication comes in such as tablet, elixir, powder inhalation, often affects absorption and metabolism
Pharmacokinetics describes how a medication enters the body, reach and active state for action, metabolized, and excreted when their effects have been obtained
Therapeutic Effect- the expected, desired effect of taking a medication vs. Side effect- expected, unavoidable effects, at therapeutic doses. Adverse effect-undesirable/unpredictable side effects, often severe, Toxic effect- may be a result of prolonged exposure to drug or excessively high dosage, accumulation in the blood, may be lethal in their results
Idiosyncratic reactions- unpredictable over or under reaction of a patient to a medication I.e. Benadryl making a child climb the walls when it should really make them sleepy.
Allergic reaction- an immune response is elicited, release of antibodies by the body -Anaphylactic- life-threatening, reaction constriction of bronchiolar muscles, edema of the pharynx/larynx, severe wheezing, ShOB
Timing: onset, peak, trough, duration, half-life,
Route: Parenteral, SQ, I'm, IV, Non-parenteral, Oral, Sublingual- under the tongue, Buccal-mucous membranes of the cheek, Topical, Inhalation, Intraocular
Measurement: Metric- mL, mg, g, L, Household- drop, cup, tbsp., tsp. , oz.

THE FIVE RIGHTS

In addition, since 1893, we have been taught the 5 rights as the number one process for safe medication administration. The five rights were first seen in The Nursing Sister: A Manual for Candidates and Novices of Hospital Communities.7 Nursing sisters taught five rights to prevent error: right patient, medication, dosage, route and time. Since then, there have been an increasing number of rights: client education, documentation, client right to refuse, assessment, and evaluation of the client after the medication is administered.8The number of rights increases, but error rates do not change. I have tried to find research to support use of the 5 rights - there isn't much out there - no randomized clinical trials showing that using the 5 (or 6, 7, 8, 9) rights improves patient safety when compared to some other method of safe medication administration.

Below you will see safety guidelines from a fundamentals of nursing clinical packet. It's what we are teaching new nursing students to do to prevent medical error.

Safety

Maintains medical asepsis, sterile technique and standard precautions
Maintains proper body alignment and personal safety
Demonstrates appropriate use of equipment provided
Provides nursing care that maintains the emotional and physical safety of patients
- and other members of the healthcare team
Demonstrates knowledge and identification of national patient safety goals
Communicates observations or concerns related to hazards and errors to patient,
- Families and the health care team, and faculty
Organize multiple responsibilities and provide care in a timely manner while using
- clinical reasoning skills to prioritize care
Safe
Accurate (each time)
Affect (each time)
With occasional or with supporting cues

And here is a clinical check-off sheet for a return demonstration for safe medication administration

administration-of-medication.jpg.076771262f08b024137b9f9ff6b3cda6.jpg

BLAME THE NURSE

It's obvious that the nurse who gave the patient insulin instead of heparin made a mistake. That nurse gave the wrong drug. That nurse didn't follow the five rights. If we stop with these statements, is it possible this error could happen again to another patient? The answer is YES. We have to go deeper if we want to prevent error. "The single greatest impediment to error prevention...is that we punish people for making mistakes" Dr. Lucian Leape9

GETTING TO THE ROOT OF THE MATTER

Doing a root cause analysis is required by the Joint Commission for sentinel events (I wrote about RCA in another blog. Below is the causal tree from the RCA for Ms. Grants death.

causal-tree-hypoglycemia.jpg.a7779bbfbcdf0fe12c47f8211f01fc42.jpg

SOLUTIONS

The causal tree shows that multiple factors contributed to the patient receiving the wrong drug. The committee that investigated the death came up with the following solutions:

Insulin was added to the automated dispensing device
Staff were educated to keep medications secured and not on drug cart
Nurses were reminded to keep med carts locked
Use of multi-dose vials of insulin and heparin prohibited
Use of saline flushes to restore patency of arterial lines required instead of heparin
Interdisciplinary team to examine how to expedite delivery of medications to patients

At the end of every Root Cause Analysis (I have lead many as a former Patient Safety Officer) we always ask, "If these interventions had been in place at the time of the event, could the error have occurred?" If the answer is "yes" then we get back to work. What do you think? Are there any other ideas you have for preventing this type of error? What experiences have you had with medical error?

SECOND VICTIMS

A "second victim" is a healthcare worker who has been involved in a medical error. Second victims often experience emotional trauma, stress, financial strain, loss of job and loss of peer respect after being involved in an error. Unfortunately, I've been there (yet another blog)

If you or someone you know has been involved in a medical error, please send them to one of these sites to get support and help:

ProPublica Patient Safety Action Network Community: Patient Safety Action Network Community Public Group | facebook

Medically Induced Trauma Support System: Home - MITSS

REFERENCES

Bates, D. W. (2002). Unexpected hypoglycemia in a cricitally ill patient. Annals of Internal Medicine, 137(2), 110-116. Retrieved from: Unexpected Hypoglycemia in a Critically Ill Patient | Annals of Internal Medicine | American College of Physicians
Kohn, L., Corrigan, J., & Donaldson, M. (2000). (Editors). To err is human: Building a safer health system.Washington DC: National Academy Press.
Classen, D., Resar, R., Griffin, F. (2011). Global "trigger tool" shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30, 581-9. doi: 10.1377/hlthaff.2011.0190.
Makary, M. & Daniel, M. (2016). Medical error - the third leading cause of death in the US. British Medical Journal, 353, 1-5. doi: 10.1136/bmj.i2139
Institute for Healthcare Improvement
Wachter, R. M. (2012). Understanding patient safety. 2nd ED. China: McGraw Hill.
Wall, B. (2001). Definite lines of influence: Catholic sisters and nurse training schools. Nursing Research, 50(5), 314-321.
Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2013). Fundamentals of nursing (8th ED.). Philadelphia, PA: Elsevier.
Leape, L., Epstein, A. M., & Hamel, M. B. (2002). A series on patient safety. Journal of the American Medical Association, 288(4), 501-508.
Patient Safety Action Network Community Public Group | facebook
Home - MITSS

Been there,done that, ASN, RN · Oct 31, 2018

Yes, of course it is preventable. "the nurse flushed the patient arterial line with insulin instead of heparin. "

You can quote all the studies you want, develop all the algorithms you want. The bottom line/ root cause is the nurse grabbed the wrong vial of medication. Most likely because they were overworked. The vials are similar in size and are available without a pharmacy check.

Heparin and insulin are high alert meds. The nurse that administered it, did not have another nurse check the administration of the high alert med.

Daisy4RN · Oct 31, 2018

I think it is always a good idea to do a f/u on any death etc. but agree with Been there, done that that sometimes mistakes will be made because of the nurse being overworked or constantly interrupted during medication admin. I would like to see hospital admin and nurse orgs do something about that.

Also, I am a little confused about your clinical med admin check sheet, you do a head to toe, and VS prior to medication admin as part of your med pass and check the 5 rights 3X? Sometimes all these extra steps are what causes a nurse to feel pressed for time which leads to mistakes.

Wuzzie · Nov 1, 2018

Checking the 5 rights that many times is not the way to do it. It becomes too rote and mistakes happen. We did the pre-flight check once and only once paying close attention to every item in it. We didn't have time to do it multiple times even if we wanted to. If we had been forced to we also would have been forced to rush it and many people's lives would have been out at risk.

Triddin · Nov 1, 2018

I've never heard of flushing an art line with heparin. Is that a standard practice?

blondy2061h, MSN, RN · Nov 1, 2018

That checklist for the student nurses is almost hilarious when you think that it's not uncommon in my area for some nurses to have 16 patients on night shift and not unheard of for patients to have meds due every 2 hours. That just isn't happening. So short cuts happen. Yes, better staffing would help. But in the meantime it's better to make a more realistic algorithm that can actually be followed so short cuts aren't necessary.

AceOfHearts<3 · Nov 1, 2018

Extra meds never belong on a med cart. I am a very firm believer in this because I almost came close to a catastrophic error once. The off-going shift left me an extra bag of insulin for my insulin drip on the med cart. I scanned out and verified another med, but when I went to hang it I accidentally grabbed the insulin bag that I forgot was there. I caught it because I always always verify that the pump matches the label on the bag and that that matches my order/MAR. Extra meds, especially high alert ones, should never be left on the med cart- it's just not worth the risk.

MunoRN, RN · Nov 1, 2018

It's these sorts of errors where we often seem to miss the forest for the trees. The problem isn't the safest way to store, draw up, and administer a heparin flush in a transduced arterial line, the problem is that there is no reason for flushing these lines with heparin in the first place. There is no benefit in terms of patency, and no reason to believe there would benefit since heparin is not a thrombolytic, and once it's been instilled into the line as a flush it will quickly be pushed through by the continuous flow of fluid from the pressure bag through the transducer.

The best solution to this scenario is to stop figuring out safest way to do something that even when done correctly has no benefit and only poses the potential for harm, and just don't do it at all.

LovingLife123 · Nov 1, 2018

I've never heard of heparin being used to flush an art line. But why were they having to draw up meds to push? There was not continuous NS going through the line to keep it patent? Then you would flush from the bag of NS. An art line should have a transducer on it. Then the NS hooked up to that with a pressure bag to keep it going at a rate of 3mL/hr.

This scenario is kind of confusing. Maybe this is how it was done years ago, and you are pulling the scenario from then. I just don't know if why anyone would ever push a med through an art line.

Wuzzie · Nov 1, 2018

LovingLife123 said:
This scenario is kind of confusing. Maybe this is how it was done years ago, and you are pulling the scenario from then. I just don't know if why anyone would ever push a med through an art line.

This wasn't done even years ago (and I'm talking three decades). The only art line I've ever pushed a med through is a UAC but that's a different animal.

JKL33 · Nov 1, 2018

The case was published in 2002 so it happened sometime before that. I will assume it was quite common still that art lines were maintained with heparinized saline (1000 units heparin/500 ml saline). Why anyone would have wanted to draw up heparin from a vial and push it to maintain an artline is what doesn't make sense.

ETA: And I dislike the fall out from people having done things that are off the rails...as if we all just go around willy-nilly doing things clearly not common/normal and killing planes full of people.

But we have had this discussion before...

K9lover, ASN, RN · Nov 1, 2018

Checklist is great if someone has one stable patient all night to thus take 35 minutes per medication.

Case Study: Can You Prevent This Medical Error?

What caused the seizures?