Intro to Error Reduction Strategies
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Transcript of Intro to Error Reduction Strategies
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Halloween Horror Stories
James Waterson.
Clinical Educator.
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How and Howstoppit?
Whodunnit?
Whydunnit?
Howdunnit? Howstoppit?
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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.
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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.
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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.
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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?
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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
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6
EVD
Patients drainage had stopped
Blood in drainage possiblystopping flow
Nurse flushed line with saline
Patient arrested immediately and
died
What happened?
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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?
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8
Doctor performing bronchoscopy
Alone in OR
Biopsied a suspicious looking area Patient died of hypovolaemic shock
Why?
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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
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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
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11
A triple pump.
TPN order.
Vamin 42 ml/hr
Lipid 2 ml/hr
2 nurses checked the
prescription
Patient died of fatEmbolus
Why?
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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?
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13
ICU patient transfer
Slide sheet used [Why?]
Patient fell between the beds Well caught! the charge nurse shouted
How did it happen
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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?
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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
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Emergency Drugs Access
Child Had 3 IV lines
He arrested
The team couldnt give him any IVadrenaline
He died
ABC Access
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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?
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