CASE STUDY IN
COMBINED SYSTEMS AND
INDIVIDUAL FAILURE
Ethan Cumbler M.D.
Assistant Professor of Medicine
Hospitalist Section
University of Colorado Hospital
2007
Case represents an example based on
real case. Some details have been
changed and case de-identified to
preserve patient confidentiality
CASE OF THE TRAUMATIC
URINARY CATHETER REMOVAL
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86 y/o male with hx
of CHF, Afib, and
Dementia presents
with increased
lower extremity
edema and SOB.
Documented to be
non-compliant with
medications for
months.
PMH
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CHF
Afib
Hypothyroid
Osteoporosis
Dementia
Parkinson’s
Urinary Incontinence
CASE
Allergies-NKDA
Medications
Noncompliant with:
 Linsinopril
 Amiodarone
 Carvedilol
 Furosemide
 Warfarin
 Asprin
 Calcium-Vit D
 Alendronate
 Carbidopa/levodopa
 Levothyroxine
Social Hx
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Lives with wife who
also has significant
dementia. APS
involved in his care
multiple occasions
Hospital Course- Day 1
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Admit to Cardiology Service. For CHF
exacerbation due to medication
noncompliance. Treating with IV
furosemide
Indwelling urinary catheter ordered.
Documented need for strict Is + Os
along with presence of stage II sacral
skin breakdown.
Hospital Course- Day 3
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Care transferred to Internal Medicine service.
Patient transitioned to oral furosemide
Medicine team is post-call and discusses patient on
“sit down rounds” (not at bedside). No mention of
urinary catheter on rounds
Medicine Attending #1 notes presence of catheter
while rounding alone later in day. Verbal order to
nurse to remove catheter.
At end of day Attending #1 discusses plan to
remove catheter with Resident. Neither Attending
#1 nor Resident write order to remove catheter.
Nurse forgets to remove catheter in response to
verbal order by Attending #1.
Hospital Course- Day 4
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Attending #1 is no longer on service
(scheduled switch at end of week).
Resident has day off
Resident and Attending do not communicate
intended catheter removal during check-out
Intern not aware of plan to remove catheter
Intern and Attending #2 do not discuss
presence of urinary catheter or plan for it’s
removal
Hospital Course- Day 5
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Intern has day off
Resident returns to service. Notes
presence of urinary catheter and
assumes that it was removed but then
replaced for a medical indication for
which resident is not aware
Hospital Course- Day 6
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Patient wakes in the middle of the night
confused. Gets out of bed and walks
towards bathroom
Catheter bag is attached to opposite side of
bed, traction rips it (with bulb inflated) out
of penis causing urethral tear and significant
bleeding
Pt had bleeding for 3 days requiring aspirin
and heparin prophylaxis to be held. Urology
consulted. Hct drops.
One week after discharge patient was
readmitted for transfusion
STRUCTURED ANALYSIS
OF MEDICAL ERROR
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Use (Systematic Analysis of a Medical Error form to
guide discussion)
Step 1
Adverse event, Medical error,
Causation
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Was There an Adverse Event?
Yes. A traumatic removal of an unnecessary
urinary catheter represents an adverse
event
Was there a Medical Error?
Yes. The failure to remove unnecessary
urinary catheter despite plan to do so
represented a medical error
Were the two related?
Yes. In this case the medical error directly
lead to the adverse event.
Step 2
Were There Systems
Issues Which Contributed
to This Error?
-Communication
-Information management
-Technology
-Supervision
-Workload
-Human resources support issues (staffing)
Systems issues
Communication
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Breakdown in intra-team communication based on
failure to discuss plan of care during team rounds
and fragmented communication of plan to remove
catheter with some but not all members of the care
team.
Failure to sign-out elements of care during
transitions off service.
Use of verbal orders- a form of communication with
nursing prone to failures and miscommunication
Diffusion of responsibility- Attending did not write
order believing that resident would do so. Resident
assumed Attending had already written order.
Systems issues
Information Management
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Check-out system not formalized to include
plan of care for items such as urinary
catheters.
Computerized nursing record tracks urinary
catheter presence but lacks connection to
physician accessed portion of electronic
medical record. Since removal of urinary
catheters is a physician-driven active
process this removes opportunity for
increased physician awareness and prevents
electronic prompts to the physicians for
removal.
Systems issues
Technology
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While decidedly low tech, the design of current
indwelling urinary catheters predisposes to this
form of urethral trauma.
Use of condom catheter rather than indwelling
catheter presents less risk of traumatic injury
(assuming the goal is strict Is+Os or skin protection
rather than obstructive uropathy)
The design of the urinary catheter which
encourages it to be attached to bed rather than the
patients leg creates a form of single point restraint
which may induce injury when a patient with
dementia tries to get out of bed.
Systems issues
Supervision
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No significant issues
Systems issues
Workload
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Nursing had multiple patients with
active issues on day of verbal order to
remove catheter. This likely
contributed to nurse forgetting to
remove catheter. Low priority request
easy to forget without reminder from
written order
Systems issues
Human Resources
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Staffing model failed to preserve
continuity of team. Both Attending
and Resident went off service on same
day. Multiple transitions between
teams during short patient
hospitalization.
Step 3
Which Type of Individual
Error Occurred?
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Knowledge based- mistake from
inadequate or incomplete information
or base of knowledge
Skill based- performance error. Not
doing the action which was intended.
We think of this as a “slip”
Rule based- the incorrect application
of the information. We think of this as
a “Judgment failure”
Step 3
Which Type of Individual
Error Occurred?
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Skill basedThe request to remove catheter was
forgotten by nurse who received the
verbal order (nurse became distracted
by other tasks and forgot to do so in
absence of written prompt)
Step 4
List Heuristic Failures
Leading to Individual
Judgment Error
There was no judgment error and thus
Heuristics failure does not apply to this case
Step 5
What Level Harm Occurred As a
Result of The Adverse Event?
123456-
No harm, error identified prior to affecting patient
Minor temporary harm
Minor permanent harm
Major temporary
Major permanent
Death
Harm
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Major temporary harm
Bleeding sufficient to require
transfusion represents a major adverse
event but the patient did not suffer
permanent injury
Step 6
What Would You Disclose In
This Case?
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In this case the fact of the urethral
trauma due to the patient accidentally
pulling out catheter in the night was
disclosed but the medical error
causing the catheter not to be
removed was not discussed.
It would be easy, but not ethically
appropriate, to pretend that no error
had occurred.
Step 6
Disclosure
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It would be appropriate to explain to patient/family
that the team had intended to remove catheter but
that this had not actually occurred during the
transitions over the weekend. The patient had
become confused in the middle of the night and
pulled the catheter out causing injury (facts of the
case). Since the plan was to remove the catheter it
is appropriate to express regret that this occurred
and an expression such as a “wish statement”. “I
recognized that with his confusion he is at
increased risk for this sort of event. There was a
good reason for the catheter to be placed but I
wish that I had removed it earlier.”
A straightforward apology is appropriate along with
an explanation of how the error will change your
practice to prevent this in the future
Disclosure will be discussed in detail in the third
seminar.
Step 7
What Steps Could be Taken
to Prevent This From
Occurring in The Future
Small group break-away sessions.
Each group should be assigned an
element contributing to the medical error
Potential Steps
Communication
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Bedside team rounding decreases chance that
issues such as urinary catheter use will not be
noticed and discussed in the plan.
Team rounds later in the day would prevent
fragmentation of communication
Creation of checklist of items to be addressed on
every patient in rounds decreases chance that
multiple necessary elements will be missed
(catheters, intravenous lines, DVT prophylaxis, skin
care ect)
Avoid verbal orders unless in emergency
Clear delineation of responsibilities for who on a
team will write orders
Potential Steps
Human Resources
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Personnel turnover is unavoidable but
certain staffing models create more
turnover than others. Staggering days
off to prevent all senior members of
the team from taking the same day off
decreases risk of discontinuity.
Potential Steps
Information Management
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Change in system of care such that multiple
members of patients care team (physicians
and nursing) are empowered to remove
urinary catheters
Creation of new system to remind team that
urinary catheters are in place. Could be
electronic in conjunction with I.T.
department or handwritten reminders in
chart. Would need interdisciplinary and
administration buy-in to institute this potent
QI step.
Potential Steps
Technology
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Preventive measures to decrease chance of
demented patients from wandering.
Assessment of wandering risk/impulsivity for
patients with dementia. Use of bed alarms
for those at high risk.
Catheter attachment to leg rather than bed
for patients at high risk
Use of condom catheters for patients with
dementia who have indication for catheter
which does not require indwelling form
Next Step
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Each small group reports back its
potential solutions. The entire group
then examines solutions to determine
which are most feasible and have
greatest potential to come up with an
action plan for a QI project.