Intro to Error Reduction Strategies

8/8/2019 Intro to Error Reduction Strategies

1/25

Halloween Horror Stories

James Waterson.

Clinical Educator.


2/25


3/25


4/25

How and Howstoppit?

Whodunnit?

Whydunnit?

Howdunnit? Howstoppit?


5/25

1

The patients epidural infusion of Fentanyl

and bupivicaine was attached to his CVC

triple lumen line. It had been infusing for the entire night

shift.


6/25

2

A small child of 8 kg.

An infusion of NA HCO3 was set up by the nurse via acentral line. The order was for20 mls of NaHCO3 to run

over2 hours for Base correction. He also had maintenance fluid running peripherally

The patient then had to go to CT Scan so the infusionswere taken off and held until return. [He had a lot ofinfusions]

A triple pump was in use. The patient returned from CT and got his Bicarb infusion

via the peripheral line.


7/25

3

Child receiving feed via an NG tube.

A chronic patent who had been on feed for

a long time Tube replaced after child displaced it

Child was fed for three days, no problems

Day 4. Child found to have a largeaspiration pneumonia. He subsequently

died.


8/25

4

Common practice in a certain ICU to place

toothpaste in syringes to share out among

the patients

Also common for patients to receive

boluses of Propofol for agitation

Any guesses on what happened?


9/25

5

10 Kg Child had ALF. pH 6.9, MAP 26 Lactate13.

Access nightmare referral from abroad

TLC and Vascath both in left femoral ICU was incredibly busy

CVVHD, HFOV, NO2, Noradrenaline

ICP [Policy]

Mottled Foot, vascular referral,the whole nine yards

Blame? Think think think


10/25

6

EVD

Patients drainage had stopped

Blood in drainage possiblystopping flow

Nurse flushed line with saline

Patient arrested immediately and

died

What happened?


11/25

7

D.O.P.E.

London, 1989, power cut hit the whole city

The ICUs of four premier hospitals Each unit had to decide which patients to

keep alive

What would WE do?


12/25

8

Doctor performing bronchoscopy

Alone in OR

Biopsied a suspicious looking area Patient died of hypovolaemic shock

Why?


13/25

9

Patient to receive NG Sucralfate [Carafate]

4 times a day 1G [10 mls]

Given IV [Color?] Three way tap

An incredibly routine drug.

Patient outcome


14/25

10

Patient with tenchkoff catheter [chronic PD]

New Peg tube for feeding

Surgical ward.

PD change done by renal nurse [2 L exchangebags]

Ward nurse started feeding

via Peg

Patient died of peritonitis What happened?

The expert practitioner


15/25


16/25

11

A triple pump.

TPN order.

Vamin 42 ml/hr

Lipid 2 ml/hr

2 nurses checked the

prescription

Patient died of fatEmbolus

Why?


17/25

12

Patient arrested while the nurse was

charting in the room

Another nurse walked into the room andsaid, hes arrested you know

How did this happen?


18/25

13

ICU patient transfer

Slide sheet used [Why?]

Patient fell between the beds Well caught! the charge nurse shouted

How did it happen


19/25

The Denver Baby Case

Mother had syphilis [Spanish-Mexican]

National ID centre advice: treat baby Benzathine penicillin G 150,000U IM

Pharmacist filling the order consulted notes and drug ref. book for infants.Misread dose [twice] as 500,000units/kilogram (kg),[adult dose] vs. 50,000units/kg. Saw order as 1,500,000 units [ U taken as zero]a 10-foldoverdose.

Labeled to be given in 2.5 ml H2O IM

Nurses worried over injections required. {Max vol 0.5 ml IM]

IV route checked in ref book. OK! With aqueous Pen G. They thought thewarning over IM benzathine was a brand name.

The nurse practitionerknew that while generally only clear liquids can beinjected IV, certain milky-looking substances can be IV., such as lipid-based

drug products, can be given IV. IV admin is lethal because the drug is insoluble and obstructs blood flow inthe lungs. The manufacturers warning was very difficult to see.

Baby died, autopsy [the old Dr joke] did not have syphilis.

Who or What was to blame?


20/25

At Trial

Three nurses grand jury for negligent homicide.At trial other colleagues indicted [50 errorsidentified]

Syringe labeling Pharmacists mistake

Confusing drug information

The system within which they acted

medication errors are almost never the fault of asingle practitioner

the nurses were acquitted


21/25


22/25

Emergency Drugs Access

Child Had 3 IV lines

He arrested

The team couldnt give him any IVadrenaline

He died

ABC Access


23/25

Food for Thought

Those who talk about foolproof

underestimate the skills of fools

How to check a pumps true delivery?

CVVHD do you trust it?


24/25


25/25

Documents

Intro to Error Reduction Strategies