Overdose or Poor Documentation?

Dramatization:

[female voice] I kept telling my husband he needed to see the doctor. He had stomach pain and blood in his stool, but he didn’t want to go through any procedures. I bugged him and bugged him until he went for a colonoscopy, and it basically killed him.

Narrator

A 41-year-old male underwent a colonoscopy with endoscopy at an ambulatory care center. He was there for evaluation of recent abdominal and rectal pain and blood in his stool. A pre-procedure evaluation was completed by the anesthesiologist and a certified registered nurse anesthetist (CRNA). The only anesthesia-related risk noted was obesity.

The CRNA administered monitored anesthesia care for the procedure. The patient may have received 200mg of propofol, possibly twice; however, the CRNA’s documentation is unclear. The procedure lasted for 30 minutes.

Once the patient was moved to the post anesthesia recovery unit, the CRNA noted that he was not breathing but had weak radial pulses. A code was called and additional staff arrived to assist with cardiopulmonary resuscitation. The CRNA began ventilating the patient via Ambu bag. She then attempted to intubate the patient, but was delayed by about a minute due to a missing piece on the laryngoscope.

Rescue medications, including epinephrine and atropine, were administered. The cardiac monitor revealed pulseless electrical activity, so CPR was continued and the patient regained a pulse. Upon transport to the hospital he was found to have severe anoxic ischemic encephalopathy. The patient did not improve or regain meaningful neurologic function, and remains in a persistent vegetative state.

The patient’s family alleged that improper management of the patient under anesthesia resulted in cardiorespiratory arrest, permanent brain damage, and persistent vegetative state. While the cause of the patient’s cardiac arrest is uncertain, experts were critical of the CRNA’s insufficient documentation, as it failed to note which medications and doses were administered during the procedure.

The case was settled for more than $1 million.

To discuss the patient safety and risk management aspects of this case, we are joined now by Julie Higden. Higden is a nurse and a patient safety program director for CRICO.

Q.) Julie, this is a tragic case for the patient and the family. From what we know about the frontline practices that were involved, what were the likely contributors to what really is an administration error?

A.) Yeah, I think what stands out for me in this case probably is the word ‘routine.’ There is nothing particularly out of the ordinary for this patient’s procedure, and there really were no sort of red flags or high-risk concerns, at least from the preop anesthesia perspective.

So we talk a lot about something called muscle memory, which just to give you an example, for me it means you get in your car and you drive to work. You’re really not thinking too much about putting the key in the ignition, putting on our seatbelts, even the route we take when we go because we’ve just done it so many times. So that’s sort of how I think of muscle memory in the clinical sense, and it could be a good thing. So for clinicians who have been a part of hundreds, maybe even thousands of these, you know, routine procedures, it’s almost like driving a car. So that’s not to say we’re not thinking about what we’re doing and we’re all being careless, but really they were really no major red flags here that signaled us or signaled the clinician that anything was out of order. So again, this can be a good thing, but I think it also presents challenges because you’re almost on autopilot and it sort of makes me wonder perhaps in this case the CRNA was sort of moving throughout the routine procedure and administered the correct dose of medication but was perhaps distracted and maybe documented it twice. Or conversely, the autopilot was so strong that the propofol was actually administered twice, and there was nothing that made the CRNA kind of take pause or really scrutinize what was happening in the moment and so an error really was made.

I think it’s hard to speculate, but these are certainly two possible scenarios. There are potentially many more like a systems error that could have contributed or distractions, equipment malfunctions, things that we may never know about, but I think these are two very possible likely scenarios.

Q.) We often talk about the five rights for safe medication practices. When reflecting on a case like this one though, should we be considering additional safeguards or additional rights, something like right documentation or right response?

A.) I absolutely think we should be considering additional safeguards when it comes to administering medications. You know, in health care and me personally in nursing school, we talked a lot of about the five rights. But I think many would make the case that there really are eight rights, even 10 or more when it comes to medication administration safety. So we hear a lot and talk a lot about right drug, right patient, right route, right dose, and right time, but I would argue that we really also need to be considering things like right response, so when you give your patient a medication, how did they respond to it? Right documentation, of course, we want to be documenting in real time so there are no issues like the one in our case study. The right reason, so understanding really, as I said, you’ve given medications hundreds of times, but do you really truly understand the reason the patient is receiving what they are. And, of course, to the extent that this is possible making sure that the patient understands and has the right education and there’s probably more than that.

But I think it sort of goes back to that muscle memory when we have administered medications hundreds of times. It’s vital to really slow down, think critically about each medication administration to really ensure optimal safety. And I know that’s not always easy when clinicians are busy and rushed and stressed, especially given the current state of health care systems, but I think to the greatest extent possible, that’s what we should be doing each and every time.

Q.) We know from the literature that there’s usually not just one thing, but there’s a cascade of process flaws that come before the patient is harmed, especially with medication. What are some of the potential systems errors in the case when you look at it and what are some of the ways we might think of to stop those?

A.) There certainly could have been several systems issues or errors that contributed to this event, again that we may never know about. There could have been something distracting happening in the environment, maybe the electronic health record was acting up or a barcode scanner was malfunctioning. I think there are many scenarios that could have been happening, but humans and systems are both imperfect, and I don’t think we’ll ever be able to stop all errors from occurring, although that certainly is the ultimate goal as it relates to patient safety.

But I think one step is really to kind of look at the strength of patient safety interventions.  There’s certainly a continuum when it comes to patient safety interventions and they include things like ‘weak,’ ‘intermediate,’ and ‘strong.’ Weak measures, for example, are things like trainings, warning labels, policies and procedures, and then our stronger interventions really can include things like changes to a physical plant or forcing functions of behavior which basically makes it very hard for somebody to do the wrong thing. So I think all of these things are very necessary to make environment safer and often it’s a combination of these different tiers of interventions that are the most beneficial, but again, I don’t know that there’s ever a way to stop all medication errors, but these are certainly some ways that we can try.

Q.) So what’s the role of other team members, nurses, anesthesiologists in the case?

A.) Yeah, you know, we often say health care is a team sport, and I fully believe that when it comes to patient safety. Really, everybody plays a very significant role in either promoting or detracting from a safe environment. So again, it’s difficult to speculate, but it is really essential to drive home the importance of each individual role and it’s vital that all team members are doing safety checks, adhering to policies and procedures, really keeping safety at the forefront and speaking up when something doesn’t seem right or if there is a concern. So in any scenario, ideally the culture is one that’s just and that speaking up by any team member is encouraged and even rewarded if there is a safety concern, but health care really is a team sport and so is patient safety.

Q.) Well thank you for sharing all of that, Julie.

Julie Higden is a nurse and a patient safety program director at CRICO. I’m Tom Augello for Medmal Insider.