Transcript Case Study 3 - Partners Radiology

Patient Safety Training
“Error Free Patient & Site Identification”
Partners Radiology Patient Safety Team
Copyright 2005
Partners Radiology
Goal
“Improve patient safety by providing
tools to assess staff competency in error
free patient and site identification”
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Partners Radiology
Objectives
At the end of the training the participant will be able
to:
– Identify how errors occur (causes)
– Identify effects of errors on patient, department
and hospital
– Discuss countermeasures
– Define & deploy the hospital specific patient
identification process
– Understand how to employ various methods for
competency assessment
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Partners Radiology
Methodology
Blame-free Approach – Share incidents, policies,
procedures and risk reduction strategies employed
 Failure Modes & Effects Analysis Approach
(FMEA) - Identify true cause and effects of sentinel
and adverse events and proactively prevent such
high-risk events from occurring by implementing
selective countermeasures.
 Root Cause Analysis – Analyze adverse and
sentinel events retrospectively to identify failures in
systems and processes

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Partners Radiology
Target Audience
 All
clinical and non-clinical personnel
involved in the patient & site
identification process - Technologists,
MDs, RNs and Support Staff
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Partners Radiology
Case Study 1
Correct patient/Incorrect chart
Non-compliance with patient
identification procedure
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Partners Radiology
Case Study 1
Mr. Chen in room 426A has been ordered
for a biliary drainage tube.
Transport is called to bring down Mr. Chan
in 428A for an abdominal CT scan.
15 minutes later, transport is called to bring
patient in 426A.
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Partners Radiology
Case Study 1
The patient is brought to interventional
radiology.
The nurse and tech review the chart for Mr.
Chan and confirm the written MD order for
the biliary procedure.
During the consent process the patient
appears to understand, nods his head in
agreement and signs the consent.
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Partners Radiology
Case Study 1
The procedure progresses with no
complications up until the guide wire is
removed. As the guide wire is removed, it is
followed by a large gush of arterial blood.
Surgical consult is immediately called and
patient is rushed to the OR for emergency
surgery of his hepatic artery.
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Partners Radiology
Case Study 1
Meanwhile in CT, Mr. Chen is asking when
his biliary tube placement is scheduled for?
The CT tech calls interventional radiology
and asks when Mr. Chen is scheduled for
his biliary drainage tube.
The interventional tech replies, “We just
finished the biliary drainage tube
placement. I better call you back”.
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Partners Radiology
Case Study 1
What happened?
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Partners Radiology
Case Study 1
What happened?

Two patients with similar names on same
floor
 Transport called for patient by room number
only
 Secretary/Unit coordinator gave transport
incorrect information due to similarity of
names
 Patient was addressed by procedure name
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Partners Radiology
Case Study 1
What happened?

Language barrier not recognized during
rush to consent patient
 Disregard for policy – no one verified name
and date of birth with patient chart
 Disregard for policy – no one verified
written order and patient’s armband
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Partners Radiology
Case Study 1
Effects
PE – Patient effects; HE – Hospital effects;
RE – Radiology effects


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
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Patient exposed to unnecessary invasive radiology
procedure, which resulted in complications (PE)
Patient almost died (PE, RE, HE)
Increased length of stay/ICU stay (HE)
Malpractice liability (HE, RE)
Patient inconvenience & decrease in patient
confidence (PE)
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Partners Radiology
Case Study 1
Effects
PE – Patient effects; HE – Hospital effects;
RE – Radiology effects





Delay in treatment of Mr. Chen (PE)
Patient care issue (RE, HE)
DPH review of case (HE)
Delay in treatment of Mr. Chan (PE)
Increased length of stay (HE, PE)
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Partners Radiology
Case Study 1
Countermeasures

Correct patient ID procedure – use of 2
valid patient identifiers – Active verification
(Ask patient to state name and DOB)

Compliance
policy
with
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patient
Partners Radiology
identification
Case Study 1
Questions
 Which of the following should be employed for
correct patient ID using patients specific name?
1. Call for the patient using patient’s last name only
(compliance with confidentiality)
2. Ask the patient to state their first and last name
3. State to the patient “ Your name is….”
4. Provide hospital interpreter service and/or
arrange for legal guardian
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Partners Radiology
Case Study 1
Questions
 Which of the following could be employed for a
second patient identifier?
1. Patient’s DOB
2. MRN
3. Referring physician's name
4. Date of last exam
5. Patient location or room number
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Partners Radiology
Case Study 2
Wrong patient scheduled by
physician’s office
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Partners Radiology
Case Study 2
Melanie Murphy, 45 year old female, arrives
at Dr. Feel Good’s office. Dr. Feel Good
instructs the secretary to order a CT study for
Ms. Murphy. The harried secretary quickly
schedules the exam and sends the patient to
Radiology.
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Partners Radiology
Case Study 2
Upon Ms. Murphy’s arrival in Radiology, the
receptionist confirms the patient name,
checks her in and enters the requisition for
Melanie Murphy.
On receiving the requisition, the technologist
goes to the waiting room and calls for
Melanie Murphy.
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Partners Radiology
Case Study 2
Ms. Murphy stands up and follows the
technologist to the exam room. The
technologist confirms the patient name and
referring physician’s name and completes
exam.
Subsequently, Melanie Murphy goes for a
follow-up visit to Dr. Feel Good’s office and
the doctor discovers that he has not received
any report for the exam in the system.
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Partners Radiology
Case Study 2
What happened?
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Partners Radiology
Case Study 2
What happened?
Referring MD’s secretary entered the wrong exam
information – incorrect DOB and/or MRN
 Radiology receptionist confirmed patient ID with
one identifier – “patient name”
 RT used one valid form of ID (patient name) and
one invalid form of ID (referring MD’s name)
 Referring MD did not use an ID specific only to
that patient – made an order based on patients
name only

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Partners Radiology
Case Study 2
Effects
PE – Patient effects; HE – Hospital effects;
RE – Radiology effects
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Patient inconvenience (PE)
Decrease in patient satisfaction/confidence (PE)
Correct patient did not get results (PE & RE)
Delay in diagnosis (PE & RE)
Wrong patient billed – Medicare fraud (PE, RE &
HE)
Revenue loss (RE & HE)
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Partners Radiology
Case Study 2
Effects
PE – Patient effects; HE – Hospital effects;
RE – Radiology effects


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Exam results sent to wrong patient chart – HIPAA
violation (PE, HE & RE)
Decrease in MD satisfaction (RE & HE)
Litigation issue (RE & HE)
Patient care issue (RE & HE)
Compliance issue – Medicare Fraud/HIPAA
violation (RE & HE)
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Partners Radiology
Case Study 2
Countermeasures

Ordering physician should confirm orders
 Secretary in office should verify two forms of
patient ID (Patient name & DOB)
 Radiology receptionist should verify two forms of
patient specific identification (JCAHO specific)
 RT should verify two forms of patient specific
identification (JCAHO specific)
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Partners Radiology
Case Study 2
Questions
True/False
 Physicians are not responsible for correctly
identifying patients.
 Technologist does not need to identify patient as
long as the radiology receptionist has done so.
 The radiology receptionist does not need to verify
the patient’s DOB as long as their name is on the
schedule.
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Partners Radiology
Case Study 3
Results sent with
wrong patient name
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Partners Radiology
Case Study 3
It is a hectic day in ultrasound. There are
multiple ultrasound guided biopsies
scheduled.
The unit coordinator has prepared the
needed paperwork for the procedures. She
affixes patient labels to unused specimen
containers.
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Partners Radiology
Case Study 3
Mr. Robinson with metastatic colon cancer
arrives in ultrasound and is brought into
room 1.
Mr. Smith also arrives for his core liver
biopsy and is brought into room 2.
Both patients’ core liver biopsies are
performed after correct patient identification
and time out.
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Partners Radiology
Case Study 3
The nurse in room 2 realizes that there is no
specimen container in the room. The MD
has the specimen ready, so the nurse rushes
from the room.
She sees one container labeled on the
counter and retrieves it. The MD then
deposits the specimen into the container.
The specimens for Mr. Smith and Mr.
Robinson are then sent to the lab.
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Partners Radiology
Case Study 3
The pathology report for Mr. Robinson
returns as benign fatty liver. The report for
Mr. Smith unfortunately shows malignant
metastatic disease.
Mr. Robinson is discharged and is
scheduled for a 6-month follow-up liver
scan.
Copyright 2005
Partners Radiology
Case Study 3
While in the hospital, a course of treatment
is planned for Mr. Smith and treatment
includes a combination of chemotherapy
and radiation therapy.
During the course of his treatment, he
becomes immunosuppressed and develops
serious MRSA pneumonia, from which he
succumbs.
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Partners Radiology
Case Study 3
On autopsy it is noted that Mr. Smith had a
fatty liver but no evidence of ever having liver
metastasis.
Mr. Robinson returns prior to his 6-month
follow-up with severe abdominal pain,
jaundice, increased bilirubin count and fever.
CT and Ultrasound exams confirm multiple
large liver lesions, lymphadenopathy and
ascites. Palliative treatment and hospice care
are initiated.
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Partners Radiology
Case Study 3
What happened?
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Partners Radiology
Case Study 3
What happened?

Neither the MD nor the RN verified patient
identification on label of container versus
patient identification on band and
requisition.
 Lab failed to verify patient identification on
requisition with label on container.
Copyright 2005
Partners Radiology
Case Study 3
Effects
PE – Patient effects; HE – Hospital effects;
RE – Radiology effects

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Patient inconvenience (PE)
Decrease in family confidence (PE)
Delay in treatment leading to death (PE, HE)
Correct patient did not get results (PE, RE)
Non-traceable specimen (PE, RE)
Decrease in MD satisfaction (HE)
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Partners Radiology
Case Study 3
Effects
PE – Patient effects; HE – Hospital effects;
RE – Radiology effects






Litigation issue (HE)
Patient care issue (PE, HE)
Compliance issue (HE, RE)
Wrong patient billed (HE, RE, PE)
DPH review of case and bad publicity (HE)
Pain and suffering for both patient and their
families (PE)
Copyright 2005
Partners Radiology
Case Study 3
Countermeasures
 Technologist
needs to verify all items related to
care of patient – label of container, requisition
and arm band
 Lab needs to follow correct patient identification
process
 Nurse or Technologist should assure all proper
equipment is in the room before procedure starts
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Partners Radiology
Case Study 3
Questions
 Who was responsible for verifying that the
label ID was correct?
1.Unit coordinator
2.RN
3.RT
4.Radiologist
5.Receiving personnel in lab
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Partners Radiology
Case Study 4
Wrong side entered in requisition
Original images misread/mislabeled
/incorrect report
Failure to follow site verification process
Copyright 2005
Partners Radiology
Case Study 4
Mr. Peter Van Don, a 60 year old male
patient with peripheral vascular disease
and bilateral renal artery stenosis was
referred by his nephrologist to a radiologist
for angiography and possible stenting of
the left renal artery.
Copyright 2005
Partners Radiology
Case Study 4
The patient was scheduled for his
procedure in the usual fashion, which was
later cancelled by the patient himself. In
the process of rescheduling the patient, the
radiologist rescheduled the patient but not
in the radiology scheduling system.
Copyright 2005
Partners Radiology
Case Study 4
When the patient arrived for his
appointment, he did not appear on the
radiology schedule and the procedure team
was not expecting him. The only information
about the patient was on a procedure
planning board. This information included
“Renal arteriogram/Stenting”.
He was treated as an add-on.
Copyright 2005
Partners Radiology
Case Study 4
The radiologist who rescheduled the
procedure was not present on this morning
to present the patient’s history at the
morning rounds but was expected to
perform the procedure later in the day.
Copyright 2005
Partners Radiology
Case Study 4
One of the fellows was dispatched to the
floor to obtain consent. He obtained a
history from the patient and wrote a preprocedure note indicating that the patient
has left renal artery stenosis: plan
procedure angiogram/stenting.
The consent form was signed by the
patient but did not indicate which renal
artery would be involved.
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Partners Radiology
Case Study 4
The original radiologist who planned to do
the procedure needed to leave at 4pm and
signed out the procedure to the on call
radiologist.
He provided a verbal report that the patient
had a stenotic renal artery and needed an
angiogram and possible stenting; he did
not specify a side.
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Partners Radiology
Case Study 4
By the time the patient was called to the
procedure room the fellow who had
obtained consent was scrubbed in another
procedure.
The pre-procedure note, consent form and
nursing assessment were in the patient’s
medical record and brought into the
procedure room along with the patient.
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Partners Radiology
Case Study 4
The nurse’s assessment and the
nephrologist’s progress note stated that the
patient was here for left artery arteriogram
and stent and the right kidney was not
salvageable.
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Partners Radiology
Case Study 4
The on call radiologist and the new fellow
assigned to this procedure did not review
the documents in the chart prior to the
procedure and did not review MRA as the
computer had crashed and they did not
want to reboot it.
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Partners Radiology
Case Study 4
Under direct visualization in the
arteriogram, the left renal artery could not
be visualized but stenosis was noted in the
right renal artery.
The radiologist believed that the right renal
artery was the one requiring treatment and
proceeded with stenting and opened blood
flow to the unsalvageable kidney.
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Partners Radiology
Case Study 4
After completing the procedure, the tech
asked the radiologist “Are we going to go
on and treat the left renal artery”.
The patient overheard this and commented
“You mean you placed the stent in my
right renal artery?
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Partners Radiology
Case Study 4
The radiologist acknowledged this and
then the patient commented in a fury “ But
you were supposed to treat the left renal
artery, my right renal artery is not
functioning”.
The patient then refused any further
treatment and signed himself out of the
hospital.
Copyright 2005
Partners Radiology
Case Study 4
What happened?
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Partners Radiology
Case Study 4
What happened?
 The
stent was placed in the wrong renal
artery
 Left kidney renal insufficiency was left
untreated, resulting in inability to perform
its function
Copyright 2005
Partners Radiology
Case Study 4
What happened?

Patients medical record not reviewed prior
to procedure

Failure to follow site verification process

Prior images were not reviewed prior to the
procedure
Copyright 2005
Partners Radiology
Case Study 4
Effects
PE – Patient effects; HE – Hospital effects;
RE – Radiology effects

Left renal artery stenosis left untreated (PE)
 Patient inconvenience and loss of patient
confidence (PE)
 Patient exposed to unnecessary radiation and
invasive procedure (PE)
 Interruption and delay in treatment of life
threatening condition (PE)
Copyright 2005
Partners Radiology
Case Study 4
Effects
PE – Patient effects; HE – Hospital effects;
RE – Radiology effects






Litigation issue (HE & RE)
Patient care issue (HE & RE)
Compliance and billing issue (HE)
Cause of sentinel event (RE)
Bad publicity (HE)
High risk of morbidity and mortality (HE, RE & PE)
Copyright 2005
Partners Radiology
Case Study 4
Countermeasures
 All
available documentation needs to be reviewed
including prior medical imaging
 The time out should be followed accurately –
“Technologist did not speak up in this case” – If
there is any question on the part of any
participating personnel, everything must stop
until discrepancies are sorted out
Copyright 2005
Partners Radiology
Case Study 4
Questions

Whose responsibility was it to speak up during
team pause?
1. Radiologist
2. Fellow
3. Technologist
4. RN
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Partners Radiology
National Patient Safety Goals
2004 - 2005

Goal # 1 - Improve the accuracy of patient
identification
- Use at least two patient identifiers (neither to
be the patient’s room number) whenever
administering medications or blood
products; taking blood samples and other
specimens for clinical testing or providing
any other treatments or procedures (Scored
at PC.5.10, EP 4)
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National Patient Safety Goals
2004 - 2005

Goal # 4 - Eliminate wrong-site, wrongpatient, wrong-procedure surgery
- Use a pre-op verification process, such as a
checklist, to confirm appropriate documents
are available
- Implement a process to mark the surgical site
and involve the patient in the process
Copyright 2005
Partners Radiology
National Patient Safety Goals
2004 - 2005

Provisions of the Universal Protocol
- Preoperative verification process
 Relevant pre-op tasks completed and
information is available and correct
- Surgical site marking
 Unambiguous mark, visible after prep &
drape
 Right/left, multiple structures or levels
Copyright 2005
Partners Radiology
National Patient Safety Goals
2004 - 2005

Provisions of the Universal Protocol
-“Time out” immediately before starting
 Involves entire team; active communication
 Fail-safe model: “No go” unless all agree
- Applicable to invasive procedures in all settings
Copyright 2005
Partners Radiology