Transcript Case Example Systems Failure

CASE STUDY IN
SYSTEMS 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-Background
 78
y/o with multiple comorbidities including
afib, DM II, CHF and CAD
 Pt was taken off warfarin 2 months before
admission due to falls.
 Underwent gallbladder removal for
symptomatic gallstones one month PTA.
 Two days PTA left lower extremity swelling
begins. Pt c/o pain from left knee to groin.
What Diagnosis Do You Suspect?
Case- PMH
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Afib
DM II with proteinurea
CAD with stent in 2007
CHF
HTN
COPD
Overactive bladder with
indwelling cath
Hyperlipidemia
Osteoporosis
Macular degeneration
Hx shingles
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PSH
Choly 1 month PTA
Cataract removal
Social History
25 pack yr smoking hx.
No ETOH
No drug use
Widowed
Lives alone
CASE-MEDS
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MEDS:
Esomeprazole
Aspirin
Digoxin
Atorvastatin
Furosamide
Lorazepam
Fiber
Norethindione
Ranitidine
Alendronate
Diltiazem XT
O2 5L
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MEDS:
Nitrofurantion
B12
Fluticasone/salmeterol
Prochlorperazine prn
Meclizine prn
Vaginal Estrogen supp.
Brimonidine opth
Latanoprost opth
Oxybutinin
Pregabalin
Fluconazole
Glyburide
What About This Case
Already Creates Higher
Than Average Risk for
Adverse Events and
Medical Error?
SET-UP
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Multiple Interacting Comorbidities
 PolypharmacyMultiple opportunities
for drug-drug
interactions
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Annual risk of Adverse
drug event in the
elderly:
<5 med4% risk
6-10 meds10% risk
11-15 meds30% risk
>15 meds55% risk
CASE-EXAM
 Vitals
150/60 37.2 76 18 98% on 5L
 Irregular
Heart Rate. Grade 3/6 SEM
 Abdomen- mildly tender RUE
 3+ edema in left lower extremity (1+ on
right)
CASE-LABS+IMAGING
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Na 133, K 4.2, Cl 98, CO2 23, BUN 25, Gluc 80
 Cr
2.0
 WBC 13.2, HB 11.2, Plt 330
 INR 1.2
 U/S DVT extending from the common
femoral vein to the distal femoral vein
CASE- Initial Assessment
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#1- DVT, over wt limit for LMWH. Start Heparin drip (used
custom 18 U/kg/hr following 80 U/kg bolus). Warfarin 5mg
qd 1st dose tonight. Stool for occult blood. Malignancy w/u
as outpt
 Increased WBC. ? Due to UTI. Bactrim.
 Afib- Check Digoxin level
 DM- hold oral agents SSI
 CAD- continue Aspirin
 COPD- O2
 HTN- Continue home meds
 Proph- Heparin drip. Change H2B to PPI
Potential Issues
 Overall
plan is reasonable- Medical team
seems to recognize increased risk of
bleeding.
 Use of custom higher than average dose of
heparin in setting of renal failure.
 Increased risk for bleeding with combination
aspirin/warfarin/heparin
 Multiple drug-drug interactions (warfarin and
antibiotic). Levels will need close monitoring.
CASE-HOSPITAL COURSE
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Day 1+2- initiated plan
 Day 4- blood pressure
noted to be relatively
low. Anemia
discussed. Aspirin
held
Day
Hb
INR
Ptt
1
11.2
1.2
32
2
10.9
3
8.9
1.3
72-73
4
8.7
1.5
64
58
153
171
CASE-HOSPITAL COURSE
 Day
5- Hb drops to 7.8.
 Assessment
notes drop in Hb. Attributes to
likely acute/subacute bleed. CT abdomen
ordered
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of rectus sheath hematoma)
CASE-HOSPITAL COURSE
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0815- order to transfuse 2 U PRBCs
 0835- nursing notes “MD will write for T+C for
possible transfusion”
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1859- type and cross completed
 2055- transfusion started
 0200 the following morning transfusion completed
Analysis of Case
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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- the bleed
represented an adverse drug event.
Was there a medical error? Yes- 17 hour 45 min delay
between ordering a transfusion and the completion of the
transfusion
Significant delay in transfusion represents a delay
between intent and outcome
(Remember that the definition of medical error does not
require harm to occur)
Did the medical error cause the adverse event- No. In
this case there is an adverse drug event but the medical
error occurred during the treatment of the adverse event
and was not a causal factor.
Step 2
Did system errors contribute to medical error?
Which types?
 Type and Cross blood sample was lost
 No feedback mechanism to trigger
investigation when blood did not arrive
 This error represents both problems with
information management and with
communication
 To determine exactly what in the system
failed, a more detailed process map was
required.
Failure Analysis
 Process
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Mapping
Between Order and Transfusion > 20 nodes
Where did things go wrong?
• Failure at Nodes
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Tech drawing multiple blood samples before sending
Blood sent by tube system to wrong location by nurse
• Lack of Nodes
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No feedback mechanism, when blood has not arrived
• Lack of Communication
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Pt sent for CT Scan before type and cross drawn
Step 3
List Individual Errors + Type
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Individual error included nurse sending type and
cross to wrong location via intra-hospital tube
system
 This represented a Skill-based Error on the part
of the nurse who accidentally sent the blood to
the wrong location.
 Looking back there was probably also
opportunity for earlier recognition of the adverse
drug event (bleeding) by the physicians with the
drop in blood counts on day #3
Step 4
List Heuristic Failures Leading to
Individual Judgment Error
 None
related directly to the medical error
which was the delay between ordering the
transfusion and the blood being transfused
Step 5
What Level Harm Occurred As a Result of
The Adverse Event?
 Rectus
sheath bleed in patient on
heparin/coumadin/and aspirin is an adverse
drug event
 Harm occurred- major temporary harm
 The adverse event was probably not directly
related to the medical error in this case.
 No evidence that harm was worsened by
delay in transfusion
Step 6
What Would You Disclose?
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In a case such as this where the process has
broken down but no harm is occurring it is
appropriate to keep the patient informed that the
transfusion is still planned but has been delayed
by difficulty processing the blood.
 A simple apology for the delay is usually
sufficient when no harm is occurring.
 A commitment to keep the patient updated is
important.
Step 7
What Could Be Done To
Prevent This In The
Future?
What Could Be Done To Prevent
This In The Future?
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Involve risk management to assist in creating
new feedback nodes between the floor nurses
and the laboratory.
 This involves change in system of care and
requires multi-disciplinary approach to creating a
solution
 Follow-up by physician to assure that ordered
events are occurring (active step which is
significantly less reliable then the system
solution described above)
References
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Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion
of Medical Errors in Morbidity and Mortality Conferences. JAMA
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C.K. Hofling et al. An Experimental Study in Nurse-Physician
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1966:171-80 (as quoted in The Lucifer Effect. Understanding how
Good People turn Evil. Philip Zimbardo Random House New York
2007)
Blumenthal D, Ferris TG. Safety in the Academic Medical Center:
Transforming Challenges Into Ingredients For Improvement.
Academic Medicine 2006;81:817-822
Murayama KM, Derossis AM, DaRosa DA, Sherman HB, Fryer JP.
A Critical Evaluation of the Morbidity and Mortality Conference.
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Spencer FC. Human Error in Hospitals and Industrial Accidents:
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References
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Buetow S, Elwyn G. Patient Safety and Patient Error. Lancet
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Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M,
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James Reason. Human Error. Cambridge University Press.
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