Epinephrine Error - Broken Heart Syndrome, Part 1

RobbiRN, RN

The Problem

Dear Mr. Thornton,

I’m writing in response to the specific questions from your email this morning. A full investigation of the tragic event in our Faster Care area is in progress. You will have access to the complete report by tomorrow afternoon. I cannot deny or confirm several specifics, but I can agree this is undoubtedly the most heartbreaking incident during my tenure at Sarnia Shores.

In response to your first question, I was attending our mandatory monthly performance review, so I was not in the department Thursday afternoon.

Second, you asked how we could have such an incompetent nurse working in our Emergency Department. Michelle, the RN responsible for the accidental IV administration of epinephrine, is a Certified Emergency Nurse with an eighteen-year track record of excellent reviews, four awards for exceptional service, and multiple letters of appreciation from our customers in her file. She has no previous documented errors or formal patient complaints.

You stated that the nurse failed the patient. Yes, she did–but first, the system failed the nurse.

When you took over as the CEO of Sarnia Shores Healthcare, I was hopeful that we would find ways to increase our efficiency. Some of the initiatives have been helpful. You will likely remember that I strongly opposed the directive to move from a triage system to a direct bedding approach in which no patient waits if a room is available regardless of patient acuity. At the time of the incident, every room in our main area was occupied, and two rescue units were waiting to off-load new arrivals. Twelve of the patients occupying our main rooms had minor or chronic conditions. Ten of those twelve patients had arrived in the hour preceding the incident. Under our previous system, some of those patients would have waited in the lobby for a Faster Care room to open. The twelve patients who did not need acute care will likely increase our satisfaction scores, but their placement in those rooms removed immediate access to limited resources from those whose lives were on the line.

The triage nurse identified Cheyenne as having an emergent, life-threatening anaphylactic reaction with her airway quickly closing. She notified the charge nurse but was told to send her to Faster Care because no main rooms were open. Faster Care is not designed to handle critical patients. There are no monitors. The nurse to patient ratio is 6 to 1 with a 45-minute door to door target time. It is designed for rapid discharges after minimal testing or treatment of non-emergent patients. A 56-year-old with active chest pain was also sent to Faster Care four minutes before Cheyenne, so Michelle already had a new potentially critical patient.

The PA in Faster Care immediately recognized that Cheyenne needed emergent intervention and pulled the Michelle from the chest pain patient to Cheyenne’s room. The PA gave Michelle verbal orders to start an IV and give three medications, one of which was an I'm injection of 0.3 mg of epinephrine. Every emergency room RN knows that we only give epinephrine IV push during a resuscitation, but, while Michelle was preparing to administer the medication, her Vocera came on, informing her that one of the rescue units was also headed to her last open room. She protested that she had two critical patients in the past few minutes and she couldn’t take another one. During the distraction of the Vocera exchange, she accidentally pushed the epinephrine IV. She immediately recognized her error, called the PA back to the bedside, and paged overhead for a rapid response.

You asked why the error was not stopped by our bedside bar-code scanning process. In many life-threatening or resuscitation situations, ER staff still work based on verbal orders and chart after the fact. Even if the medication had been entered in the computer system and scanned at the bedside, the nurse would have ultimately been responsible for the route of administration. The computer can confirm the medication matches an order for a specific patient, but it cannot control how the nurse gives it. There is no question that the medication was ordered to be given I'm.

The rapid response was appropriate, and no other deviations from standard practice have been identified. I can confirm the results you noted as they are in the permanent record. Cheyenne’s heart rate shot to 200 beats a minute before slowing to 130 over the next nine minutes. The EKG showed she remained in a sinus rhythm. She experienced severe tightness in her chest and shortness of breath. The troponin drawn immediately after the incident was 0.01 while the repeat level three hours later was elevated to 0.36, consistent with damage to the heart muscle. The echo cardiogram clearly demonstrated a reduced ejection fraction of 40% and atypical Takotsubo cardiomyopathy, an abnormal ballooning of the left ventricle. A cardiac catheterization did not find any blocked cardiac arteries. After starting two medications, Cheyenne continues to experience random rapid rates over 150 at rest and up to 180 with minimal exertion.

As I stated at the outset, the full report will be available tomorrow.

I need you to know Michelle is mortified. She hasn’t slept and struggles to eat. She will carry her part of this tragedy for the rest of her life. I personally share the sadness and pain of this misfortune on several levels. Cheyenne has excelled here in her role here as a Health Unit Coordinator/Patient Care Tech in our department over the past two years, and I have become very fond of her. She is well-liked by her co-workers, and many here are devastated. We share the fear of her uncertain future. We will support Cheyenne in every way we can. She is our family too.

I am deeply sorry. I didn’t know she was your niece until I received your email this morning.

Sincerely,

Sharon Goodwin

Author's note: Takotsubo cardiomyopathy and the subsequent IST (Inappropriate Sinus Tachycardia) are often poorly understood, misdiagnosed, and marginalized.

Epinephrine Error - Broken Heart Syndrome, Part 1

The Problem

In Epinephrine Error, Part 2,we’ll look at Cheyenne’s ongoing quest for healing a year after the epinephrine error.

About RobbiRN, RN

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