Comprehensive Notes on Preventing Medical Errors and Responding to Harm
Introduction to Medical Errors and Patient Safety
Doctors and nurses, despite their dedication, are human and can make mistakes.
Despite progress, medical errors remain too frequent, highlighting the need for safer healthcare systems.
The Importance of Addressing Medical Errors
Lucian Leap introduces a series of educational videos focusing on:
Prevention of medical errors.
Responding to harm caused by care.
Cases of medical errors will be analyzed to develop improvements in care systems.
Complete elimination of errors is unlikely, making proper response crucial.
Impact of Medical Errors on Patients and Families
Errors can be devastating, shaking patient trust.
How caregivers respond defines their character and profession.
Silence and avoidance are common but harmful responses.
Open communication is vital for healing and closure.
Empowering Patients and Families
Patients and families should be active partners in their care.
They can provide essential input that caregivers may miss.
Cases in the series illustrate common events and learning opportunities.
Case Study: Lewis Blackman
The first case involves Lewis Blackman, offering learning opportunities for caregivers, patients, and families.
Viewers are encouraged to pause, discuss, and reflect on the unfolding events.
The goal is to improve understanding of safety issues and prevent recurrence.
Lewis Blackman's story begins with a code blue alert in room 517.
Lewis Blackman's Background
Lewis, a 15-year-old, was admitted for electrosurgical repair of pectus excavatum.
He was otherwise healthy and active.
Pectus excavatum surgery was considered intrusive until a new, less invasive procedure became available.
The Blackman family decided to proceed with the surgery, drawn by the promise of a safe, minimally invasive correction.
Educational Objectives
Viewers will learn to:
List the benefits of a robust informed consent process.
Describe how diagnostic errors contribute to patient harm.
Define premature closure and its impact on diagnostic errors.
Understand the importance of calling for help.
Appreciate empowering nurses and physicians to call for help.
Describe the value of a rapid response process.
Define transparency for caregivers, patients, and families.
Describe patient and family expectations when harm occurs.
Recognize the importance of patient and family observations in investigations.
The Surgical Procedure and Initial Post-operative Period
Lewis underwent a two-hour operation with a thoracic epidural placed for pain control.
60 \text{mg} of IV ketorolac was prescribed every six hours for pain.
The surgeon reported the procedure went well.
Staff were concerned about low urine output in the recovery room.
Due to a lack of beds, Lewis was admitted to a pediatric oncology floor.
His urine output remained low, and he experienced nausea and vomiting.
Informed Consent and Patient Awareness
Patients and families should know:
Their condition.
Treatment options and alternatives.
Risks and benefits.
Hospital stay details, procedures, and medications.
Lewis experienced problems from the start, including no urine in his bladder during surgery.
This issue was not adequately addressed, and he was sent to the oncology floor instead of pediatric surgery.
Post-operative Day 1
Lewis’s first post-operative day was slightly better.
His pain was rated between 2 and 4 out of 5.
Urine output increased after IV fluids were increased.
Nausea persisted, and he couldn't take fluids orally.
He continued to receive epidural analgesics and IV ketorolac every six hours.
Lewis was constantly sweating and unable to keep anything down.
His diet was advanced on his chart, but he couldn't eat anything.
Patient-Centered Care
Patient-centered care focuses on the individual, not just their condition.
In Lewis's case, it meant recognizing him as a beloved son, brother, and a star student involved in community theater.
Weekend Care and Vigilance
Lewis's surgeon examined him on Friday evening and reported he was progressing well.
On Saturday morning, the attending surgeon also said everything was going well.
Vital signs remained stable.
Lewis continued to have nausea and chest pain.
Patients should be aware that weekend care may differ from weekday care.
Hospitals may not be as well-staffed on weekends and nights.
Cross-coverage by residents unfamiliar with patients is common.
Effective handoffs are essential.
Deteriorating Condition
By Sunday, Lewis’s condition worsened.
At 6 AM, he received another dose of ketorolac.
He was unable to eat or drink.
At 6:30 AM, he experienced severe abdominal pain, rated 5 out of 5, distinct from his surgical pain.
He also reported groin and penile pain.
The nurse attributed the pain to gas or constipation.
His blood pressure and heart rate increased.
Caregivers attributed his abdominal pain to constipation and penile pain to his Foley catheter.
The Foley catheter and thoracic epidural were discontinued.
Oral oxycodone was added to the ketorolac for pain management.
Lewis’s abdominal pain briefly subsided but returned by 12 PM.
The nursing staff recommended he sit up, take a bath, and walk around.
Communication Breakdown and Lack of Attention
The family felt helpless and unable to get appropriate help.
They were unaware of how to escalate their concerns.
There are different "tribes" in healthcare (doctors, nurses, etc.) with internal hierarchies.
Miscommunication can occur within and between these groups.
The family requested an attending physician but felt their concerns were dismissed.
Bad things often happen over weekends due to reduced staffing.
There is a culture in medicine against asking for help unless absolutely necessary.
Lewis appeared to be rapidly declining, but his symptoms were not adequately addressed.
Vital signs were recorded but not interpreted in context.
The system seemed to be operating for its own benefit, with the patient as an afterthought.
Families are constant in the patient’s life and can detect nuanced changes.
Misdiagnosis and Neglect
Between 8 and 10 PM on Sunday, a physician examined Lewis and noted stable vital signs, despite conflicting information recorded by a nurse.
Lewis's abdomen was distended, tender, and hard, and he was pale and diaphoretic.
The physician diagnosed probable ileus secondary to narcotics.
Individual symptoms were ignored or discounted instead of being seen as a coherent pattern.
Premature Closure
Premature closure involves quickly jumping to a conclusion without careful consideration.
In Lewis’s case, the assumption was constipation, ignoring serious abnormalities in heart rate and blood pressure.
The question "What's the worst it could be?" was not asked.
Diagnostic Errors
Diagnostic errors are a leading cause of patient harm.
An estimated 40,000 to 80,000 US hospital deaths result from diagnostic errors annually.
The frequency of diagnostic errors may approximate 15 \text{%}.
Confirmation Bias
Confirmation bias involves seeking information confirming an initial diagnosis while ignoring conflicting data.
Care providers focused on confirming constipation, ignoring other symptoms.
Physicians may not appreciate the possibility of being wrong and may remain confident despite conflicting signs.
Confidence is often valued over uncertainty, making caregivers hesitant to appear unsure.
Further Decline and Neglect
By morning, despite Lewis's pain disappearing, his condition had not improved.
He still had no bowel sounds, had not urinated, and had no function.
This sudden lack of pain was misinterpreted as improvement.
Some staff understood the seriousness of Lewis’s condition but did not communicate it to the family.
A blood pressure discrepancy was dismissed as equipment malfunction, leading to a search for a working cuff instead of addressing the underlying issue.
At 9:30 AM, the resident reported to the attending surgeon that Lewis had no blood pressure.
The surgeon's concern was diffused by the resident's earlier report of improvement.
At 10:45 AM, a blood pressure of 110/58 was recorded.
Shortly after, an electrocardiogram documented a heart rate of 163 beats per minute.
At 12 PM, Lewis was given another dose of ketorolac.
Cardiac Arrest and Death
Attempts to draw blood were difficult, with little blood available.
Lewis reported, "It's going black," before going into cardiac arrest.
At 12:05 PM, Lewis became unresponsive and went into full cardiac arrest.
Chest tubes were inserted by the resident, who believed Lewis had a pneumothorax.
A code was called at 12:20 PM.
Lewis was pronounced dead at 1:21 PM on Monday, November 6.
Aftermath and Initial Response
The family was informed of Lewis's death by a pastor.
They were told that the cause of death was unknown and that the chief resident had seen him the night before and found nothing wrong.
The family learned that the doctor they had requested the night before was not an attending physician.
The hospital did not immediately contact the family for information or conduct a thorough investigation.
Instead, they sent literature on coping with grieving.
Acknowledging and Addressing Mistakes
Doing the right thing after an adverse event is crucial for healing and closure.
For too long, healthcare has been characterized by silence and a lack of transparency.
More patients and families are demanding the truth, and more caregivers are recognizing the need to provide it.
In the aftermath of adverse outcomes, compassion, empathy, and honesty are essential.
Ongoing, honest communication can maintain trust between patients, families, and care providers.
The institution should commit to investigating the event and maintaining close communication with the family.
All parties involved, including the family and care providers, should be given the opportunity to heal and learn from each other.
The healthcare system must take ownership of what happened to Lewis.
Just Culture and Accountability
The principles of Just Culture and Reason’s unsafe acts algorithm should be applied to determine the appropriate response to errors.
System errors should be addressed with understanding and support for those involved.
Reckless behavior should be met with accountability.
Autopsy and Contributing Factors
Lewis's autopsy revealed 2,000 cc's of bloody fluid and 800 cc's of chocolate brown blood clot in his abdomen.
There was a perforated duodenal ulcer eroding into the gastroduodenal artery.
Four years prior, an article in JAMA discussed the association between ketorolac and gastrointestinal bleeding and death.
Numerous case reports had also detailed this association.
The caregivers did not appear mindful of this risk.
The FDA now mandates a black box warning on ketorolac's package insert.
Seeking Closure and Accountability
Eventually, one of the doctors acknowledged the hospital's responsibility and offered support.
The family was able to obtain medical records and meet with pediatric surgeons to address their questions.
The Importance of Transparency
Transparency and open communication are essential to prevent future mistakes.
The Lewis Blackman Act
The Lewis Blackman Act was passed in South Carolina in February 2005.
It requires:
Identification of all hospital staff by name, title, department, and job status.
Implementation of an emergency call system for patients, such as a rapid response team.
Failure to Rescue
Failure to rescue is a concept highlighted by the story of a woman whose mother died due to similar circumstances.
Conclusion
Lewis's death underscores the importance of patient safety and quality improvement.
Openly discussing and analyzing errors can improve systems of care.
Creating a culture of caring and compassion can help patients and their families after harm occurs.
Special thanks to Helen Haskell and her family for sharing their story and contributing to healthcare improvement.