Case Study: Can You Prevent This Medical Error?

[SafetyNurse1968]

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:

1. Generic- given by the original manufacturer which becomes the drugs official name, vs. Trade- name under which the drug is marketed.
2. Look-alike/sound-alike drugs- list produced by the Institute for Safe Medication Practices and the Joint Commission.
3. Classification- indicates the effect of the drug on the body/site of action.
4. Medication Form- the form the medication comes in such as tablet, elixir, powder inhalation, often affects absorption and metabolism
5. Pharmacokinetics describes how a medication enters the body, reach and active state for action, metabolized, and excreted when their effects have been obtained
6. 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
7. 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.
8. 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
9. Timing: onset, peak, trough, duration, half-life,
10. Route: Parenteral, SQ, I'm, IV, Non-parenteral, Oral, Sublingual- under the tongue, Buccal-mucous membranes of the cheek, Topical, Inhalation, Intraocular
11. 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

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.

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

 

[Life's Too Short, ADN, LPN]

Long time reader, first time poster.

This one struck a chord with me as I almost made this exact mistake. Order for 5000 units/1ml heparin subQ q8hr. Our heparin is dispensed in individual vials. Though individual patient meds are pulled and stored in individual drawers on our wow's. It is (was) not uncommon to find a vial of humalog or humalin sitting on top of the wow as these are 'multi draw' vials. I had scanned this patient, scanned the heparin and set it on the wow. You can see where this is going. I was talking to the patient and answering questions from her grown daughter as I drew up 1 ml of lispro into a TB syringe!

Fortunately I routinely stop just prior to giving meds to the patient to recheck everything. When I looked at the heparin vial and noticed the orange cap still intact, my stomach dropped, as I realized what I had done.

Somehow I remained composed with the patient, walked over to the sharps and dropped that 100 units of lispro in and started over. As I left the room, visibly shaking at what could have happened, I count my blessings that my Fundamentals teacher drilled us with the 5 rights over and over and over again. Thank you Ms Jackson!

I shared the incident with my manager, wrote up a 'near miss' incident report, and continue to share this story with other nurses on my unit , especially new nurses. You will never see a vial of insulin (or anything!) sitting on my wow unless I am preparing that dose. When I see a vial on someone else's wow, I will secure it. Overstepping? Maybe. But we wouldn't leave an oxy laying around, and a vial of insulin could do a lot more damage.

Slow down, pay attention and check, recheck, and check again.

[psu_213, BSN, RN]

Obviously a large amount of blame rests with the nurse. And some of it may have to do with the nurse being overworked. However, I think we would miss an opportunity to prevent similar errors in the future if we just say that it was 2/2 an overworked nurse.

Why was the line being flushed with heparin? Not that 2002 (or earlier) was the dark ages, but this incident may have helped to lead to the idea that a flush with NS is sufficient to keep the line patent. If heparin is being used, why does the nurse have to draw it up rather than having prefilled syringes? Why does the heparin vial look so much like the insulin vial? The article address these and other causes that lead to the error, and I think we do a great disservice if we just write this up to an overworked nurse.

[Wuzzie]

psu_213 said:

Why was the line being flushed with heparin? Not that 2002 (or earlier) was the dark ages, but this incident may have helped to lead to the idea that a flush with NS is sufficient to keep the line patent.

We weren't flushing a-lines with Heparin even in the 80's.

[Susie2310]

Good article and a very necessary reminder of why it is so important not to cut corners using the "Five Rights." I remember my nursing instructors from over 20 years ago telling us that when medication mistakes are made by nurses it's usually because of nurses not following the "Five Rights" for three checks, and that we should never take short-cuts with medication administration, and this has been true in my experience.

To give medications safely it's also necessary to know the patient's allergies, the indications for the patient getting the medication, the action of the medication, the expected effects, normal side effects, adverse effects and action to take, drug interactions, contraindications to receiving the medication, monitoring necessary after administration, assessment necessary prior to giving specific medications such as LOC, BP, heart rate, cardiac rhythm, respiratory rate/depth, electrolytes, other relevant lab values, kidney function, urine output, etc., and to know any other information about administering the medication that is necessary for patient safety.

[blondy2061h, MSN, RN]

SobreRN said:

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

It's good for a student to get good habits, too, I guess. Then become more efficient later.

[blondy2061h, MSN, RN]

Quote

Long time reader, first time poster.

This one struck a chord with me as I almost made this exact mistake. Order for 5000 units/1ml heparin subQ q8hr. Our heparin is dispensed in individual vials. Though individual patient meds are pulled and stored in individual drawers on our WOW!'s. It is (was) not uncommon to find a vial of humalog or humalin sitting on top of the WOW! as these are 'multi draw' vials. I had scanned this patient, scanned the heparin and set it on the WOW!. You can see where this is going. I was talking to the patient and answering questions from her grown daughter as I drew up 1 ml of lispro into a TB syringe!

Fortunately I routinely stop just prior to giving meds to the patient to recheck everything. When I looked at the heparin vial and noticed the orange cap still intact, my stomach dropped, as I realized what I had done.

Somehow I remained composed with the patient, walked over to the sharps and dropped that 100 units of lispro in and started over. As I left the room, visibly shaking at what could have happened, I count my blessings that my Fundamentals teacher drilled us with the 5 rights over and over and over again. Thank you Ms Jackson!

I shared the incident with my manager, wrote up a 'near miss' incident report, and continue to share this story with other nurses on my unit , especially new nurses. You will never see a vial of insulin (or anything!) sitting on my WOW! unless I am preparing that dose. When I see a vial on someone else's WOW!, I will secure it. Overstepping? Maybe. But we wouldn't leave an oxy laying around, and a vial of insulin could do a lot more damage.

Slow down, pay attention and check, recheck, and check again.

Thank you so much for sharing this and taking steps to prevent it from happening again!

[Diploma'82]

In the old days art line flush bags had heparin in them but that fell out of favor several years ago. I have only flushed art lines with the bag of saline hanging.

[tiddles]

I'd like to know what kinds of errors are killing hundreds of thousands of people. Are we talking blatant administration errors? I imagine a huge factor would be polypharmacy among the elderly population - drug interactions, inappropriate doses ordered, allergies/reactions etc. I wonder what percentage is actual nurse-given, wrong med/dose etc.

[SafetyNurse1968, BSN, MSN, PhD]

Daisy4RN said:

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.

I agree - but this is the check-off sheet that is used for seniors - it isn't up to me to make changes - I am showing you what I was given. Someday maybe I will be faculty and can advocate for check-offs that are based more on real world nursing.

[SafetyNurse1968, BSN, MSN, PhD]

Been there,done that said:

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.

I appreciate your comments, and I am wondering how just blaming the nurse prevents the problem from happening again?

[SafetyNurse1968, BSN, MSN, PhD]

Triddin said:

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

It used to be, the article was published in 2002.

[SafetyNurse1968, BSN, MSN, PhD]

MunoRN said:

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.

SO true - this happened back in 2002, and best practice has certainly changed a lot since then!