Week 11

Quality & Safety

1. Read the case study at the end of chapter 11.

Instructions: After reading case study, please write a short paragraph depicting which were the most important failures that led to the near death event of the patient?

What did you think was the most important contributor of all?

HISTORICAL CASE STUDY #1: Failure to Adequately Monitor a Postsurgical Patient

DESCRIPTION OF THE EVENT

This error-event involved inadequate monitoring of a patient who had undergone an elective surgical procedure. A certified nursing assistant made a proximal error when she failed repeatedly to report abnormal vital signs to a registered nurse assigned to the patient. The patient was receiving narcotics via a patient-controlled infusion device. The patient was obese and had a large neck. He also had a history of sleep apnea. This combination of factors may have combined to cause respiratory depression that resulted in abnormal vital signs.

The nursing assistant’s reporting was inadequate, and consequently the registered nurse was unaware of the patient’s low blood pressure. The patient’s condition subsequently deteriorated to the point where he was seriously compromised and near death, and may have been permanently harmed as a result.

DEMOGRAPHICS

This error-event occurred in a community hospital setting. In this event the investigation revealed that three people made errors that constituted unsafe acts and resulted in harm to the patient. These included the nursing assistant, the registered nurse (who was prepared at the associate degree level), the registered nurse in the charge/staff nurse role, and a board-certified surgeon.

The registered nurse and surgeon agreed to be interviewed, but the nursing assistant declined. Three additional people were indirectly involved and participated in the interview process. They were the oncoming registered nurse (prepared at the associate degree level of nursing), a registered (associate degree) respiratory therapist on duty, and the associate degree registered nurse house supervisor.

The root cause analysis group included two of the people who engaged in unsafe acts, one other person who was directly involved, and six additional people with expertise in the routine practices and processes of the surgical unit and related areas.

SETTING ELEMENTS

The incident occurred during one 12-hour shift between Friday at 7:00 PM and Saturday at 7:30 AM. All of the individuals directly involved in the event were working a regularly scheduled shift. The two employees who carried out the unsafe acts were working the night shift. The surgeon involved in the case had not worked the night before.

BACKGROUND INFORMATION

In the hospital setting, patients often receive pain medication through a pump that provides a specific dose on demand with a programmed maximum dose allotment. The patient-controlled analgesia (PCA) pump is programmed to deliver specific, small dosages of the medication only when the patient pushes a specified button. Therefore, if the patient is unable to push the button, he/she does not receive any more of the medication via the pump.

NARRATIVE OF THE EVENT

A young man, Mr. Steve Goldberg, was admitted to a surgical unit at 6:00 PM after an elective laparoscopic gastric bypass surgical procedure. Mr. Goldberg was stable at the time of admission and was receiving a patient-controlled narcotic infusion at a “high-normal” range for pain management via a PCA pump. He was receiving oxygen via a nasal cannula at 2 liters per minute.

On admission to the surgical unit, Mr. Goldberg’s blood pressure was stable at 142/87. He stated that he was comfortable but at times appeared uncomfortable and restless. At 8:50 PM, the patient denied having pain and wanted his oxygen removed. His oxygen levels were adequate, and the respiratory therapist removed the oxygen cannula at that time but left it in the room per routine procedure. Mr. Goldberg continued to be restless throughout the evening and was observed repositioning himself in the bed for comfort.

At midnight, the nursing assistant, Ms. Veronica Martin, removed the blood pressure cuff from Mr. Goldberg’s arm for comfort after recording a blood pressure of 92/44. She did not inform the registered nurse, Ms. Margaret Bennington, of the decrease in blood pressure but recorded the blood pressure on her worksheet, a nonpermanent record on a clipboard that contained the vital signs of the patients assigned to her. The nursing assistants used the worksheet to record vital signs for the registered nurse’s review before documenting them in the permanent medical record.

At midnight, however, Nurse Bennington was busy admitting a new patient. One hour later (1:00 AM), Nursing Assistant Martin repeated the blood pressure measurement and documented a blood pressure of 76/34 on her worksheet. Again, Nursing Assistant Martin did not report the increasingly lowered blood pressure to Nurse Bennington.

Nurse Bennington stated that at 2:45 AM she checked on Mr. Goldberg and characterized him as being restless, able to hold a conversation, and complaining of being too hot. Nurse Bennington gave Mr. Goldberg a cool wet cloth and took his blanket off. Nurse Bennington did not check any additional vital signs or ask to see the recorded blood pressure readings, stating that she assumed the patient was stable.

One hour later (3:45 AM), Nursing Assistant Martin was assigned for a short time to another unit. She did not communicate any information to Nurse Bennington regarding Mr. Goldberg before leaving the unit. She returned approximately one and one-half hours later.

At 5:15 AM, Nursing Assistant Martin returned to the clinical unit and recorded Mr. Goldberg’s vital signs as 77/34, pulse 100, and respirations 20. Nursing Assistant Martin gave Nurse Bennington a brief report on a second patient and then left to take a third patient’s vital signs.

At 5:30 AM, the surgeon, Dr. Steel, came in earlier than his usual time to evaluate the patient. Dr. Steel’s intentions were to quickly assess the patient and then leave for the airport where he had an early commercial flight to catch. Dr. Steel stated that he could hear Mr. Goldberg snoring as he approached the room, and when he entered Mr. Goldberg’s room, he found the patient cyanotic from the neck up and unresponsive to verbal stimuli. Dr. Steel left the room to get Nurse Bennington for help, and together they returned to Mr. Goldberg’s room.

Nurse Bennington stated that Mr. Goldberg was positioned on his side, which was unusual, and that it was obvious he wasn’t doing well. His color was poor, respirations were slow, and he was unresponsive. At this time, Nurse Bennington repositioned Mr. Goldberg on his back to open his airway and improve his breathing.

Over the next 50 minutes, the narcotic infusion was discarded and Mr. Goldberg received two doses of medication to reverse the effects of the narcotic infusion. His arterial blood gases were assessed, and his oxygen was reinstituted via nasal cannula. He remained on the surgical unit for approximately 50 minutes while, according to each of the three staff members interviewed, Dr. Steel was reclined in a chair in the corner of the patient’s room or at the nurses’ station making phone calls while they suggested interventions to him.

The three registered nurses interviewed expressed concerns about their perceived delays in treatment after Mr. Goldberg was discovered in his unstable condition, and attributed the delays to waiting for Dr. Steel to take the initiative. According to Dr. Steel, he reinstituted Mr. Goldberg’s oxygen, instructed Nurse Bennington to turn off the patient-controlled narcotic infusion, and to give the medication to reverse the effects of the narcotic.

Dr. Steel left to catch his plane before the patient was stabilized. Mr. Goldberg showed some improvement before Dr. Steel left. Dr. Steel stated that he thought the patient’s systolic blood pressure was approximately 100, and he had oxygen saturation levels of approximately 92%. Neurologically, his pupils were reacting slightly; he was posturing on his left side and flaccid on the right side, and remained unresponsive to verbal stimuli.

Mr. Goldberg was transferred to the intensive care unit at 6:20 AM where the nurses in the ICU quickly increased the oxygen support and added intravenous vasopressors per protocol after consultation with the on-call physician in internal medicine, Dr. Asvall. A gap of approximately 30 minutes occurred between the time Dr. Steel left for the airport and the time Dr. Asvall arrived to manage the case.

PATIENT OUTCOME

A near-death event and possible permanent patient harm was attributed to a series of unsafe acts. The unsafe acts resulted in respiratory and circulatory compromise, brain ischemia, and a small myocardial infarction (heart attack) to a young man, Mr. Steve Goldberg, who had undergone elective surgery.

THE PRIMARY CATEGORY OF ERROR

The primary category of error in this event is inappropriate judgment by Nursing Assistant Martin, the individual most proximal to the patient’s harm. Nursing Assistant Martin’s actions demonstrated inappropriate judgment in not notifying Nurse Bennington of Mr. Goldberg’s condition at the time she obtained a blood pressure reading that was substantially lower than the patient’s prior recorded blood pressures.

INDIVIDUAL CONTRIBUTIONS

It is difficult to know why Nursing Assistant Martin did not report her findings to Nurse Bennington because Nursing Assistant Martin did not participate in the interview or RCA process. She had the experience and training to know that the change in blood pressure was significant and reportable. Members of a review team that conducted root cause analyses wondered if Nursing Assistant Martin thought the blood pressure reading was inaccurate because of equipment problems. Mr. Goldberg was obese, a condition that can make accurate blood pressure readings from an arm cuff difficult and inaccurate, even when a large-sized cuff is used. Regardless, the appropriate action and standard operating procedure in the unit was for a nursing assistant to inform the registered nurse so that the registered nurse could then evaluate the patient and determine the underlying problem.

Nursing Assistant Martin did not seek assistance from Nurse Bennington immediately or over the course of the next several hours in spite of additional blood pressure readings that were well below the norm for any healthy adult. As a result, Mr. Goldberg’s deteriorating status was not noticed and he was harmed.

In addition to inappropriate judgment, Nursing Assistant Martin’s actions also reflect a communication failure with Nurse Bennington, verbally and in writing. Not only did Nursing Assistant Martin fail to seek out a face-to-face interaction with Nurse Bennington, Nursing Assistant Martin did not initiate any actions through her documentation to ensure that Nurse Bennington reviewed Mr. Goldberg’s vital signs.

Nursing Assistant Martin’s actions also demonstrated a lack of attentiveness or surveillance of Mr. Goldberg. She did not return and take additional blood pressure readings or attempt to replace any equipment as a result of the low blood pressure readings. Rather, she maintained her routine schedule, added no further interventions, and resumed her routine rounds to collect vital sign readings. Nursing Assistant Martin knew that she would be reassigned to another unit at some time during the shift. Perhaps this knowledge was distracting to her and contributed to her lack of attentiveness.

Nurse Bennington demonstrated poor judgment when she did not adequately supervise an unlicensed assistive person, Nursing Assistant Martin. It is the responsibility of the registered nurse assigned to a specific patient (in this case the staff/charge registered nurse) to oversee a patient’s care whether or not components of that care are delegated to a certified nursing assistant or to another team member. This supervisory oversight was not present in this error-event, and this left a “fresh” postoperative patient who required monitoring and more frequent assessment per nursing standards without registered nurse oversight.

A registered nurse has the authority and responsibility to assess, evaluate, and use nursing judgment when caring for patients during times that unlicensed assistive personnel are assisting with, but not replacing, the functions the registered nurse is expected to carry out (

NCSBN, 1995

). The staff/charge registered nurse, Nurse Bennington, did not act responsibly to meet the needs of Mr. Goldberg, a postsurgical patient, and used inappropriate judgment when she focused on specific tasks or demands and did not recognize the vulnerabilities of a patient that, in this instance, involved the potential for a compromised airway secondary to his anatomy and narcotic dosing.

Nurse Bennington’s actions or inactions also demonstrated a lack of attentiveness or surveillance related to Mr. Goldberg’s compromised respiratory and hemodynamic status, and related to symptoms that went undetected for several hours, according to the arterial blood gas results. Further, Nurse Bennington did not effectively monitor Mr. Goldberg, a postoperative patient, during an unsafe period of time and did not detect substandard care on the part of Nursing Assistant Martin.

Nurse Bennington also used inappropriate judgment in that she did not insist on having adequate information on a postoperative patient. She did not seek out Mr. Goldberg’s information and therefore was unable to evaluate, in a timely manner, Mr. Goldberg’s response to therapy such as narcotic infusion and pain management. In addition, she did not demonstrate good judgment in supervising Nursing Assistant Martin, a person she described as “a little too independent” and “very task oriented,” and as someone who did not pass along information “unless asked.” Knowing this, Nurse Bennington could have given Nursing Assistant Martin more specific instructions and sought out the information Nurse Bennington needed to adequately monitor the patient. Nursing Assistant Martin was inadequately monitored and Nurse Bennington did not evaluate the effectiveness of the delegated assignment.

TEAM CONTRIBUTIONS

This situation involved poor communication, coordination of effort, and follow-up that occurred between Nurse Bennington, the staff/charge registered nurse, and Nursing Assistant Martin. The team contributed to the delay in responding to a deteriorating patient through lack of or poor communication, coordination of effort, follow-up, feedback, and competency.

Nurse Bennington, the staff/charge registered nurse, expressed reluctance to overload the other registered nurse with whom she was working. Her concern for his competency affected the coordination of care on the unit. Nurse Bennington stated that the novice registered nurse had recently completed his orientation and described him as “smart, but lacks life experience.” Thus, because of this reluctance to overload her team member, Nurse Bennington took the midnight patient admission assignment, which would normally have been assigned to the other registered nurse. With this additional patient, she now had five patients of the nine on the unit with the help of Nursing Assistant Martin, who was assigned to all nine patients. This was considered a “reasonable” assignment in this particular unit where the team often assumed the care for seven patients per one registered nurse, depending on patient acuity. Normally the two registered nurses would assist each other as needed throughout the shift. The inexperienced registered nurse reportedly did not assist Nurse Bennington with her workload, however, because “he had his hands full” according to Nurse Bennington.

A team dynamic that repeatedly surfaced in the interviews was the “paralysis” of the team in communicating with each other and coordinating the care for the patient’s deteriorated condition because of the presence and behavior of the surgeon, Dr. Steel. The participants in the meeting reported that the surgeon’s actions and inaction contributed to the delays in patient interventions at a time when fast action was needed. One registered nurse stated that, in hindsight; she would “go after it a little bit more aggressively next time. I wished after it was over that I had, regardless of the doctor.” She added, “But a doctor that is sitting back in a chair looking over stuff and asking the same question over and over again—I don’t remember what it was but he asked the same question three times that had nothing to do with what was going on.”

Dr. Steel also contributed to poor communication, coordination of effort, and follow-up by leaving, or perhaps abandoning, a patient for whom he had responsibility; this resulted in a 20- to 30-minute gap in physician coverage at a time when the patient was unstable.

In nursing practice, patient abandonment occurs when a nurse accepts an assignment and responsibility for patients yet leaves the assignment without notifying his/her supervisor or other responsible staff member and does not communicate the need for another nurse to cover a patient’s condition and needs (

Benner et al., 2002

).

Abandonment is not as clearly defined for physicians in a hospital setting. In this case, however, Dr. Steel removed himself from a newly unresponsive and unstable patient before obtaining replacement coverage, although he may have been available by phone during the gap.

Dr. Steel and the team also failed to communicate effectively with each other about the patient’s care needs. One registered nurse stated the following related to Dr. Steel:

· “I felt like he was much disengaged. He was in his own thought process. He was concerned about his flight. I didn’t know what his thought processes were. If he could have shared what he was thinking or what his plan was, or shared anything, it would have felt better because then we could have had a dialogue. But there was no dialogue.”

Dr. Steel’s perception of the situation was quite different from the rest of the group, however. He stated that he felt that he “actually came out the hero in the deal” in that he happened to be “the lucky one that found Mr. Goldberg.” “From that point of view” he noted, “I feel good that I was there and intervened.”

The communication within the group was such that Dr. Steel did not receive any feedback of the group’s perception of his actions nor did he learn of their concerns about his decision to leave the patient. The gap also included the house supervisor registered nurse who was the person on the team with the authority to take action.

SYSTEM CONTRIBUTIONS

Two system factors contributed to the error-event. The first was a lack of adequate system controls, or standard operating procedures and training, for the following two critical operations. The first was caring for the high-risk surgical patient and reporting of critical data between registered nurses and nursing assistants. The second was lack of follow-up for a critical operation—physician coverage for high-risk patients.

The surgical unit did not have adequate system controls. Each registered nurse had his/her own particular way of obtaining information from the nursing assistants rather than following a standardized process. This may have contributed to the error in this instance if the nursing assistant’s expectations were for the registered nurse to review the worksheet and vital signs on a regular basis without the nursing assistant assuming responsibility for initiating the activity.

Poor system controls were also evident by the lack of patient care protocols and staff training for the patient population cared for in this case. The root cause analysis revealed that the staff was not aware of the many risk factors of the obese patient undergoing this particular procedure. Although some of the staff had attended an in-service training session on the new procedure, a patient care protocol had not been developed to standardize the care practices and adequately prepare the health care team for the risks, care needs, and appropriate interventions for this patient population.

A risk factor of significance in this case is the anatomy of obese patients undergoing this surgery. Often their anatomy puts them at risk for a compromised airway, particularly when they are receiving narcotics that can also suppress respirations.

Lack of follow-up for a critical operation was shown through the failed oversight of the physician’s behavior and his medical practice. Informally, two internists involved with the case expressed their unhappiness that the surgeon left town without ensuring adequate coverage the morning after elective surgery was performed on his patient.

The system did provide a standard that would ensure efficient and effective coverage for physicians who must leave town. The surgeon, however, did not follow the standard. When the surgeon’s case underwent the peer review process through the medical staff, the surgeon’s peers deemed the actions and treatment as “appropriate,” and had no recommendations or sanctions. Therefore the system did not use its authority to insist on effective standards and did not implement proper actions for following up on deviant behavior.

CONCLUSIONS

This study of one error-event suggests that health care organizations must go beyond the root cause analysis approach of problem solving to include a whole-systems approach. The philosophy that errors occur because of the failures of practitioners must be reframed as one that views practitioners as valued members who create safety by overcoming hazards and providing safe environments. In this reframing, patient care errors are viewed primarily as a result of practitioners becoming overwhelmed by unsafe conditions rather than the fault of single individuals who fail. This view, in contrast to a constricted expectation of individual responsibility, promotes a whole-systems thinking approach that examines the systems, team dynamics, individuals, and collective norms, beliefs, and behaviors in the context of an error-event.

The TERCAP data collection instrument was pivotal in identifying individual and system contributors to error. Interviews added much additional information related to the team dynamics within the organizational context that would most likely not be available from a retrospective review of a practitioner’s documentation of an event. Creating more reliable health care organizations requires that the organizational members, nurses, physicians, health care administrator leaders, and other employees possess an understanding of not only the chain of events that contribute to an error-event, but also of the individual, team, and collective norms and values that drive their behaviors in the organization. Further, a better understanding of these multiple contributors to error needs to evolve into a willingness to change fundamentally the way health care teams view their roles and the way leaders view the organization. Leaders have the responsibility of creating structures and managing organizations so that their practitioners and organizational members are supported and acknowledged for their role in patient safety, specifically practice breakdown prevention, intervention and mitigation.

References

P. Benner, V. Sheets, P. Uris, K. Malloch, K. Schwed, D. Jamison: Individual, practice, and system causes of errors in nursing: A taxonomy. Journal of Nursing Administration. 32(10), 2002, 509–523.

M.R. Chassin, R.W. Galvin: The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. Journal of the American Medical Association. 280(11), 1998, 1000–1005.

National Council of State Boards of Nursing (NCSBN): In Delegation concepts and decision-making process National Council position paper. 1995, Available online (with password) at 

www.ncsbn.org/public/regulation/delegation_documents_delegati.htm

, Accessed November 1, 2008.

M. Schwaninger: Managing complexity—The path toward intelligent organizations. Systemic Practice and Action Research. 13(2), 2000, 207–241.

K. Scott: In Errors and failures in complex health-care systems: Individual, team, system and cultural contributors. 2004, Union Institute & University, Cincinnati, Unpublished doctoral dissertation.

J. Speelman: JCAHO Summary of the Sentinel Events Standard Requirements. HealthBeat. 1(1), 2001, 1–7.