Saturday, June 29, 2013

I Told You. No You Didn't.

Gather around boys and girls. It's time for another Morbidity and Mortality discussion courtesy of the California Department of Public Health. Every few months the DPH releases a list of fines meted out to hospitals for egregious acts of incompetence. If you go through the list, you will see that, sadly, retention of foreign bodies, such as lap sponges and Babcock clamps, are still occurring all too frequently during surgeries. However there are a couple of interesting cases here that I would like to highlight. Luckily on this go around there are no anesthesia related incidents.

First up is a sad tale of the perils of not double checking the medications that are given to patients. A patient was admitted to Marin General Hospital in Marin County for sepsis and pneumonia. Antibiotics was ordered. After the nurse hanged what she thought was Ceftriaxone, the patient's heart rate and blood pressure dropped precipitously. The BP bottomed out at 51/30 while the heart rate went from the 90's down to the 50's. He was intubated to support his ventilation. It turned out the nurse had started a Labetalol drip instead of antibiotics. Once the error was realized, the drug was quickly stopped and the BP brought back up.

Unfortunately the patient suffered acute renal failure because of the poor perfusion. He had to go on dialysis. He also developed shock liver and rising LFT's. The hypotension also caused severe ischemia of his extremities. He was in excruciating pain due to gangrene of his lower legs and fingers. He required a Dilaudid drip to placate his pain. At this point the family decided to withdraw life support and he passed away.

During the investigation it was noted that the Labetalol and Ceftriaxone bottles were similar in size though in different colors. In addition, Labetalol came in a liquid while Ceftriaxone was in powder form that required it to be dissolved before giving to a patient. How the nurse got the two medications mixed up may never be known since he or she was not made available to the investigators for an interview. The hospital was fined $75,000.

The second case that I hope you read is a cautionary tale on the increasing prevalence of employee doctors and the shift work mentality that could set in. At Palomar Health Downtown Campus in San Diego County, nurses were having a difficult time caring for an alcoholic patient. The patient repeatedly tried to get out of bed despite warnings that he could fall. While the nurses were giving afternoon report during shift change, a loud thud was heard from the patient's room. When they walked in, they found that he had fallen out of bed onto the floor. A CT scan of the head showed he had a 2 cm subdural hematoma and a 3 mm midline shift of the brain. The on call physician was notified of the results and he ordered hourly neurologic exams only.

During the night the patient became progressively less responsive. He also became tachycardic into the 150's but this information was not forwarded to the doctor. By 5:38 AM, the phlebotomist came into his room and was unable to rouse the patient. She called the nurse to come see him. The nurse couldn't wake him up either and gave him a Glasgow Coma Scale of 3. He saw the doctor sitting at the nurses station and told him about the patient's deteriorating condition. According to the nurse, the doctor told him that he was off duty and to tell the oncoming physician about it. When the morning doctor arrived at 6:00 AM, he immediately called the Rapid Response Team and the patient was transferred to the ICU. When a repeat CT was ordered, it found that the subdural hematoma had increased and he was now bleeding into his brain stem. The neurosurgical team was consulted and declared him inoperable. He was made DNR and died the next day. The hospital was fined $100,000.

When the physician from that morning was asked about his disregard for the patient's condition, he told investigators that he was never notified by a nurse about the patient. He considered it "absurd" that he would brush off the nurse and punt the problem to the next doctor. Now who is more credible, the nurse or the physician? Who's lying? Who knows? As we train new doctors with strict work hour rules, how likely is this attitude to prevail in the future? When doctors increasingly become employees of large medical organizations, will they become like government employees who put a "Next Window Please" sign in your face just when you reach the counter?

Try to take the time to read through these investigations. There is a good reason why the state publishes these mistakes for all to study. They are an incredibly valuable resource for learning about and preventing medical errors. I've just scratched the tip of the iceberg. View what happens when a baby was accidentally injected with methergine instead of the laboring mom. Or how a guidewire from a central line kit was discovered in a patient's heart. If you know about it, hopefully it will never happen to you.

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