Epinephrine Error - Broken Heart Syndrome, Part 1

RobbiRN, RN

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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.

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

JKL33 · Oct 25, 2019

On 10/25/2019 at 9:01 AM, RobbiRN said:
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.

This is how it is.

I sincerely hope the writer actually wrote all of those things.

If this is real, etc., I am sorry and hope everyone is okay.

💛

spotangel, BSN, MSN, DNP, RN, APRN, NP · Oct 25, 2019

"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."

Sounds like the system was set up to fail the nurse. When staff that uses the system are not consulted, the chances for error multiply rapidly. Hopefully the CEO looked at changing the system and not just blame the nurse!

JBMmom, MSN · Oct 25, 2019

What an awful situation for the patient and the nurse. I can only imagine how difficult this has been for everyone. If the CEO's first response was to actually ask how they could have such an incompetent nurse working in the emergency department, without having all the information, that's the sign of an administrator that really has no understanding of their own staffing, and no compassion for staff. Unfortunately, there would be so many scapegoats at every level that this will never get up to the people responsible for setting up such an awful system. It's all about those stupid survey scores, not providing the best medical treatment.

adventure_rn, BSN · Oct 25, 2019

I'm just here to add that I think it's fantastic that this letter suggests the manager/supervisor is supporting the nurse and calling out administrative demands that sound as though they were broken from the beginning. Unfortunately, not all units support their nurses when a sentinel event like that happens.

This whole thing makes me so sick to my stomach. If errors like that can happen to the very best of nurses who are in bad circumstances, what hope is there for the rest of us? I really appreciated that the author defended the nurse's well-established credibility and acknowledged how traumatizing an error can be for the nurse who committed it. Those nurses need empathy and support, not punitive judgement.

Also, it's so important to hold upper management accountable for their demands and demonstrate why certain staffing practices are unsafe. I really appreciated the part where the author (respectfully) stated, "Remember back when I told you this staffing expectation was a really bad idea? Here's why." ...Aww snap.

Kudos to the author for standing up for his/her employees.

Kooky Korky, BSN, RN · Oct 25, 2019

We are all so fallible. Nurses, administrators, etc.

I pray for Michelle, Cheyenne, and everyone else to receive comfort, healing, and the courage to carry on.

I pray for nurses who will stand up and speak up when those who are not working in direct care try to force improper procedures and policies upon them.

As we see from this very sad article, the workers who are actually working on the front line must be involved in making the rules.

Those who won't speak up could be the next to be caught in the downward spiral.

RobbiRN, RN · Oct 26, 2019

On 10/25/2019 at 10:31 AM, JKL33 said:
This is how it is.
I sincerely hope the writer actually wrote all of those things.
If this is real, etc., I am sorry and hope everyone is okay.

It is very real and close to home. The writer did write all those things. Everyone is not okay. But, there is still hope for healing. Stay tuned for part two.

RobbiRN, RN · Oct 26, 2019

6 hours ago, spotangel said:
"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."
Sounds like the system was set up to fail the nurse. When staff that uses the system are not consulted, the chances for error multiply rapidly. Hopefully the CEO looked at changing the system and not just blame the nurse!

So far, the system remains firmly entrenched.

Milscent · Oct 26, 2019

I pray that everyone involved be ok! Many lessons learnt here and the most important one is nurses on the floor to be directly involved in decision making as they know and have seen what works and what doesn't.

applesxoranges, BSN, RN · Oct 26, 2019

Root cause analysis. This is why I try to scan everything that I can.

Technically you could push epi for an allergic reaction but not ideal and it was the wrong concentration anyway. Most of the paramedic protocols have pulled it. We also could start epi drips for anaphylaxis but usually they have them ordered for cardiac reasons under the wrong order set.

RobbiRN, RN · Oct 27, 2019

7 hours ago, applesxoranges said:
Technically you could push epi for an allergic reaction but not ideal and it was the wrong concentration anyway. Most of the paramedic protocols have pulled it. We also could start epi drips for anaphylaxis but usually they have them ordered for cardiac reasons under the wrong order set.

I think it's best to start with the idea that we only give Epinephrine IV push during a resuscitation, and seriously question pushing it in any other setting. The recommended IV dose for refractory anaphylactic shock is 0.1 mg over 5 minutes = ultra slow push. In Cheyenne's case 0.3 mg was pushed in less than 5 seconds.

medic 2 RN, ADN, RN, EMT-P · Oct 27, 2019

The last anaphylactic shock that I worked was given two, 0.3 mg IV doses of 1:10,000 epinephrine. It saved her life from a wasp sting, her epi-pen had no effect on the reaction. The patient was in her 40s, and she had no ill effects from the IV epi. I didn't push it in 5 seconds, more like 3 minutes. This was when I was still working EMS.

RobbiRN, RN · Oct 28, 2019

23 hours ago, medic 2 RN said:
The last anaphylactic shock that I worked was given two, 0.3 mg IV doses of 1:10,000 epinephrine. It saved her life from a wasp sting, her epi-pen had no effect on the reaction. The patient was in her 40s, and she had no ill effects from the IV epi. I didn't push it in 5 seconds, more like 3 minutes. This was when I was still working EMS.

A good outcome is a good outcome, but I wonder how long ago this happened? The dose is 3x the current recommendations I've seen. Do you know if that protocol is still in place and what it's based on? Cheyenne's outcome is clearly a bad one, validating the strong warnings about potential cardiac damage with IV epinephrine.

I'm curious if you have any knowledge of your patient's outcomes over time? Cheyenne's reaction also cleared. One might argue that had the epi been given IM as ordered, it would have been insufficient. We'll never know. It was given rapid IV push, and Cheyenne faces an uncertain future with a damaged heart. Do you know how well your patient did after you dropped her at the hospital? Even though she did well initially, are you certain there were no ill effects later?

medic 2 RN, ADN, RN, EMT-P · Oct 29, 2019

10 hours ago, RobbiRN said:
A good outcome is a good outcome, but I wonder how long ago this happened? The dose is 3x the current recommendations I've seen. Do you know if that protocol is still in place and what it's based on? Cheyenne's outcome is clearly a bad one, validating the strong warnings about potential cardiac damage with IV epinephrine.
I'm curious if you have any knowledge of your patient's outcomes over time? Cheyenne's reaction also cleared. One might argue that had the epi been given IM as ordered, it would have been insufficient. We'll never know. It was given rapid IV push, and Cheyenne faces an uncertain future with a damaged heart. Do you know how well your patient did after you dropped her at the hospital? Even though she did well initially, are you certain there were no ill effects later?

This was two years ago, and yes the protocol is still in place. I do know the family and she is doing fine. The protocol has been in place for many years and does need to be updated to current treatment modalities. The various services where I have worked over the years have used the 0.3 to 0.5 mg of 1:10,000 solution for severe anaphylactic reactions since 1987 at least. The protocol for this particular service was updated to IM epi 0.3 mg of 1:1,000 for mild to moderate reactions last year.

Epinephrine Error - Broken Heart Syndrome, Part 1

Epinephrine Error: Why Was it Not Stopped?

The Problem

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

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