Patient Safety at LLUMC
Quality Review/RCA
»16-20 per year
»32 in 2012
»Variety of cases
~Medication events
~Retained foreign objects
~Sedation
~Procedure issues
Quality Review/RCA
»Process issues, not individual error or
evaluation of professional practice
»Become aware via
~Electronic Event Report
~Phone call
~Conversations
~Other
Quality Review/RCA process
»Details from source
»Review records
»Interview those involved
»Timeline
»Meet to discuss
»Identify issues, determine actions
Swiss Cheese model
Case – Oxygen tank transport
»The patient, a 26 week premature infant, was
transported to the NICU on 4/23/05 in an open
warmer by the nurse and RCP. The oxygen
tank was secured to the open warmer with tape
on both ends of the tank. The oxygen tank
bumped into a bin located in the hallway
knocking the tank off the open warmer, and
inadvertently extubating the infant
Case – Oxygen tank transport
»Policy:
The infant warmers should have brackets
for attaching oxygen tanks during transport.
If no bracket is available, the oxygen tank
should be transported in a wheeled carrier.
Case – Oxygen tank transport
»The warmer used did not have the bracket for
oxygen transport. New warmers were
purchased after brackets had been installed on
all existing warmers. Brackets were not
installed on the new warmers.
»Inspections of the warmers had not revealed the
lack of brackets. Staff were aware of the
problem, unknown whether it had been reported
Case – Oxygen tank transport
Actions:
~Survey all warmers, gurneys, beds, etc. for
compliance with oxygen tank transport
requirements. Order brackets and install on
warmers
~Re-educate staff on correct procedure
~House-wide re-education on correct procedure
~Add Oxygen tank security to Environmental
Rounds checklist
Case – Wrong medication
This 34 month old girl was in the OR for an outpatient
procedure - laryngoscopy/bronchoscopy. The Anesthesia
practitioner removed a vial from the Zofran bin in the Acudose
for administration at the end of the case. The medication was
administered prior to extubation, as usual, to prevent nausea
and the child taken to the PACU(2800). The patient did not
awaken as soon as expected. Another practitioner attempted
to remove a dose of Zofran from the same bin, and found that
there were four vials of Presodex in the Zofran bin. When
this was communicated with other staff in the area, it was
found that the med given to this pt was actually Presodex.
Case – Wrong medication
Actions
~Discuss event with the techs involved,
emphasizing correct behavior
~Assess current use of Fill sheet for restocking
Accudose cabinets
~Evaluate restocking protocol for needed
changes, and implement as appropriate
~Staff reminded of the importance of checking
medication labels, not just appearance
Example…
Cefotaxime
Ceftriaxone
Case – Feeding tube placement
1/ 3
0543
1504
Feeding
tube
replaced,
x-ray
taken to
verify
location
1/ 5
1/ 4
continuous
feeding via
flexiflo tube
Pt kept
touching
NG tube.
Mittens
applied
2245
1915
NG tube
found
on bed
RN
attempting to
insert NG,
experiencing
difficulty
confirming
placement
after several
attempts.
Two other
RNs called in
to help.
Unable to
confirm
location of
tube. RNs
reluctant to
pull and try
again because
of number of
attempts and
nares
becoming
traumatized.
2325
2350
Night call
Resident
notified re:
difficulty in
confirming
placement
of tube. xray ordered
KUB
done
0025
Resident
opened KUB
film on IMPAX,
reviewed it, and
called unit with
telephone order
ok to use the
tube.
0705
0030
tube
feeding
restarted
(45 cc/
hr?)
No changes
observed in
patient
status
during the
rest of the
shift
RN checked
tube
placement,
checked for
residual and
white fluid
obtained.
Crackles heard
in lungs, RT
notified for
breathing tx
see VS graphs.
Temp 100.0
1019
VS returned,
CPR stopped
1059
1100
CXR
done
Pt
transferred
to 9100
1157
1059 CXR read by
Radiology as NG
tube in right lung,
worse aeration of
right middle and
lower lobes,
suspect
pulmonary
edema
1230
Discussion with
family - decision
to withdraw
treatment
1535
Pt expired
Patient
status
appeared to
be stable,
no unusual
cough or
altered LOC,
no apparent
distress.
1003
1030
Pt
unresponsive,
O2 sat 70. Pt
pulse felt to be
thready. RRT
called, then
pulse lost and
Code called.
KUB from
2350 read
by
Radiology.
Feeding
tube seen in
lung.
Radiology
called Dr.
Case – Feeding tube placement
Actions:
~Assessment of resident abilities to interpret basic
studies
~Encourage use of Radiology resident
consultation for interpretation
~Work on process for “2nd victim” support
~Work on process for modifying culture – team
approach, encourage calls for assistance/backup
Case – Wrong side procedure
2/21
0700
Dr R discussed
possible
benefit of
postop block
for pt with
Ortho Surgeon.
Dr. R. spoke
with patient
and obtained
verbal consent
for block.
0944
Dr. R. called
Dr. B. and told
him the pt
would require
postop fem
block. Asked
CRNA to call
Dr. B when
case done
Pt had
surgery,
then to
PACU for
recovery
1145
Anesthesia
attending Dr. C
went into
PACU and
discussed
block with
patient.
Patient
reached for
her right knee
through the
covers and said
it was sore
(had previous
procedures on
R knee).
Dr. C. exposed
and prepped
right groin area.
Did not expose
or look at entire
right or left
extremity or
observe surg
site.
Dr. C. asked
resident Dr. B.
to do the block
after Dr. C. did
the prep. Dr.
B. did as
instructed,
placed block
on R. Did not
verify
laterality.
Ultrasound
was used to
place catheter,
instead of
nerve
stimulator, so
the leg was not
fully exposed.
(If nerve
stimulator
used, would
have removed
blanket to
observe
twitches and
seen no
surgery on that
leg)
Patient
transferred
from PACU to
unit. Floor
nurse noticed
that pain
pump had
been placed on
the right side.
Paged Dr. C.
1430
Dr. C.
returned to
the bedside,
evaluated
pt, told pt
he had
made a
mistake
1512
Block placed
on L side and
discontinued
catheter on R.
Case – Wrong side procedure
Actions:
~Anesthesia personnel to obtain written
procedural consent for all blocks, filled out by
the person obtaining the consent
~Time-out process for blocks, to include the
peri-anesthesia RN
Communication
A review of QR/RCA cases showed that
about 80% of the cases involved teamwork
and communication issues.
Case – Perforated bowel
Meds:
N = Norco
P = Percocet
M = Motrin
V = Valium
D = Dilaudid
41 y.o. male admitted 1/6/09 d/t blunt chest and abd trauma. R. chest, RLQ abd pain, forehead laceration. Found to have R rib
fractures, bone fragment C5 (unknown if acute or chronic), possible R renal laceration/contusion, possible hematoma R ureter/IVC,
small amt mesenteric fluid. Bowel appeared unremarkable.
Admitted to Trauma service, 8200
1/ 8
1/ 9
V5
0600
Prog note:
Pain 8/10,
abd >chest,
on Norco
q4hr ATC.
Abd soft,
+BS, tender
RLQ/R flank
D1
M
D1
N
N
0748
Nrsg
assessment:
HR 130,
BP 100/68,
O2 sat 95.
Alert &
oriented,
skin warm,
abd soft, reg
diet. Urine
clear yellow
D1
V5
0955
1130
Pain med
changed
from
Percocet
to Norco
Attending
note: Now
has gross
hematuria,
just now
getting
OOB to
ambulate.
Abd soft
0009
0020
0035
Dr. KO
returned
page,
ordered
500cc NS
bolus and
stat CBC
Dr. KO at
bedside.
Anesthesia,
X-ray,
Respiratory
called.
Senior
resident
Turay
paged
0040
Code Blue
called. HR
125, BP 58/
35 O2 sat 85
D8
M
P
1400
1450
T 99.3,
HR 132,
BP 109/65,
Sat 92%
1540
New order
for Tylenol
prn fever/
pain
0047
HR 61,
intubation
underway and
lines being
placed.
order to
DC Norco,
start
Percocet
po q4hr
prn
1633
T 100.3 HR
132
BP 91/62,
sat 94%
D1
M
1940
Nrsg
assessment:
T 96.3,
HR 127,
BP 74/51,
sat 97.
Abd pain 10/
10. Abd soft,
distended.
Urine pink.
Skin cold,
diaphoretic.
Trauma paged
re: BP
0050
0102
0105
Intubated,
lines in, PEA,
cardiac
compressions
started
4 units
PRBCs
Transf.
HR 137160
Resident KO
(PGY2)
received page,
asked resident
SC (who had
been on during
day) to see pt/
fam. SC
changed pain
med to
Dilaudid 4-8
mg po ATC
and 1 mg IV
for BTP
V5
D1
D1
2049
2212
T 97.0,
HR 128, BP
93/48, sat
92%. Pain
10/10
nurse paged
resident KO
re: pt pain
10/10,
diaph.
Resident
"did not get
page"
2300
nurse
asisted pt
to
bathroom
with
walker
2345
0003
T 97.5
HR 131
BP 87/48
sat 91%
Nurse
paged
resident
KO
Nurse new, just off
orientation.
unit busy, charge nurse
occupied with other issues
0116
0120
to OR via
bed with
Code
Team
in OR,
Anesth
induction
pt arrested again at
time of incision. CPR
initiated. 500mL blood
in peritoneal cavity.
Perforation of distal
small bowel found.
Some liver injury, no
splenic injury.
30 min of CPR,
no cardiac
activity, pupils
fixed and
dilated.
Resuscitation
stopped.
Case – Perforated bowel
Actions:
~Continue to implement “TeamSTEPPS”
~Reinforce nursing report up chain of command
~Reinforce with residents – when called to talk
with patient/family, re-assess patient to be able
to speak to current situation
Focus for Safety
»Report safety issues
»Be alert to “you see what you expect to
see” situations
»Clear communication – written and verbal
»Teamwork – don’t be afraid to get backup,
clarify, ask for help. Recognize limitations
»Don’t skip safety processes