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 transportActions:

~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 medicationActions

~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

Feeding tube

replaced, x-ray

taken to verify

location

1504 0543 1915 2325 2350 0030 0705

1019

VS returned, CPR stopped

Patient status

appeared to be stable,

no unusual cough or

altered LOC, no apparent

distress.

RN checked tube

placement, checked for residual and white fluid obtained.

Crackles heard in lungs, RT notified for breathing tx

No changes observed in

patient status

during the rest of the

shift

1/ 3

continuous feeding via flexiflo tube

1/ 4

Pt kept touching NG tube. Mittens applied

1/ 5

KUB done

tube feeding

restarted(45 cc/

hr?)

KUB from 2350 read

by Radiology.

Feeding tube seen in

lung. Radiology called Dr.

Night call Resident

notified re: difficulty in confirming placement of tube. x-ray ordered

CXR done

1030

1059 1157

Unable to confirm

location of tube. RNs

reluctant to pull and try

again because of number of attempts and

nares becoming

traumatized.

Pt transferred

to 91001059 CXR read by Radiology as NG

tube in right lung, worse aeration of right middle and

lower lobes, suspect

pulmonary edema

2245

RN attempting to

insert NG, experiencing

difficulty confirming placement

after several attempts. Two other

RNs called in to help.

0025

Resident opened KUB

film on IMPAX, reviewed it, and called unit with telephone order

ok to use the tube.

1100 15351230

Pt expiredDiscussion with family - decision

to withdraw treatment

1003

Pt unresponsive, O2 sat 70. Pt

pulse felt to be thready. RRT called, then

pulse lost and Code called.

NG tube found on bed

see VS graphs. Temp 100.0

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

0700 0944 1145 1430 1512

Block placed on L side and discontinued

catheter on R.

Dr. C. returned to the bedside,

evaluated pt, told pt

he had made a mistake

Patient transferred

from PACU to unit. Floor

nurse noticed that pain

pump had been placed on the right side. Paged Dr. C.

2/21

Dr. R. spoke with patient and obtained

verbal consent for block.

Dr. R. called Dr. B. and told

him the pt would require

postop fem block. Asked CRNA to call Dr. B when case done

Dr R discussed possible

benefit of postop block

for pt with Ortho Surgeon.

Pt had surgery, then to

PACU for recovery

Dr. C. exposed and prepped

right groin area. Did not expose

or look at entire right or left extremity or observe surg

site.

Patient reached for

her right knee through the

covers and said it was sore

(had previous procedures on

R knee).

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.

Anesthesia attending Dr. C

went into PACU and discussed block with

patient.

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)

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 bowelMeds:N = NorcoP = PercocetM = MotrinV = ValiumD = Dilaudid

0600 0748 15401130 1633

T 100.3 HR 132

BP 91/62, sat 94%

14000955 22122049 2300

0047

Senior resident

Turay paged

HR 61, intubation

underway and lines being

placed.

nurse asisted pt

to bathroom

with walker

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"

1/ 8

Nrsg assessment:

HR 130, BP 100/68, O2 sat 95.

Alert & oriented,

skin warm, abd soft, reg diet. Urine

clear yellow

Attending note: Now has gross

hematuria, just now getting OOB to

ambulate. Abd soft

order to DC Norco,

start Percocet po q4hr

prn

T 99.3, HR 132,

BP 109/65, Sat 92%

T 97.5HR 131

BP 87/48sat 91%

Nurse paged

resident KO

Prog note:Pain 8/10,

abd >chest, on Norco q4hr ATC. Abd soft,

+BS, tender RLQ/R flank

Dr. KO returned

page, ordered 500cc NS bolus and stat CBC

0003

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

0009 00400035

30 min of CPR, no cardiac

activity, pupils fixed and dilated.

Resuscitation stopped.

Code Blue called. HR

125, BP 58/35 O2 sat 85

to OR via bed with

Code Team

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

1450

New order for Tylenol prn fever/

pain

0020 0050 0102 0105 0116 0120

Intubated, lines in, PEA,

cardiac compressions

started

4 units PRBCs Transf.

HR 137-160 in OR,

Anesth induction

Dr. KO at bedside.

Anesthesia, X-ray,

Respiratory called.

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.

2345

Nurse new, just off orientation.

Pain med changed

from Percocet to Norco

unit busy, charge nurse occupied with other issues

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

1/ 9

N N V 5 V 5

D 8M

M PD 1

D 1 D 1

D 1 D 1 D 1V 5 M

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