Failure to Read Back Physician Order Causes Patient Death

By ThinkReliability Staff

A patient suffering from pneumonia required a bedside bronchoscopy in a California hospital.  In order to provide sedation for the procedure, the physician performing the procedure requested a dose of Versed.  Although the actual dosage requested was not recorded, the nurse gave the patient 2 milligrams via IV and, a minute later, another 2 milligrams.  The maximum published dose for Versed is 1.5 milligrams over no less than 2 minutes.

Because of the bedside scenario and the verbal order for medication, the nurse was required by hospital policy to repeat back the order.  He did not, so there was no opportunity for the physician to realize the error.  Within a few minutes, the patient stopped breathing and was administered CPR.  However, the patient never regained consciousness and died nine days later.

We can look at this issue within a Cause Map, a visual root cause analysis that addresses all the cause-and-effect relationships that resulted in the issue being investigated.  The analysis begins with the impacted goals.  In this case, the patient safety goal is impacted due to the patient death.  The failure to follow hospital policy regarding repeat back of verbal orders is an impact to the compliance goal.  The patient services goal is impacted by the overdose that was administered.  The overdose resulted in extra care required for the patient, an impact to the labor goal.  As a result of the issue, the hospital was fined $50,000 by the California Department of Public Health.  (Click here to read the report, which was used to create this blog.)

Beginning with an impacted goal and asking “Why” questions adds more detail to the analysis.  In this case, the overdose occurred due to the need for Versed and the larger than ordered dose.  The larger than ordered dose resulted from a miscommunication between the physician, who ordered the Versed, and the nurse, who administered it.  The nurse did not repeat back the order as required, and the physician did not request a repeat back.  Although the requirement was apparently for the person receiving the order to repeat back, patient safety is everyone’s responsibility.  Pausing the procedure to ask for a repeat back would have likely saved the life of this patient.

Not mentioned in the analysis was the conditions under which the order and procedure were performed.  Clearly ability to hear was a concern.  A study published in May of 2013 determined that background noise in the operating room can result in difficulty in communication between team members, not only by affecting team members’ ability to hear each other, but could also impair an individual’s ability to process auditory information.  Other studies have found that other environmental factors can impact medical errors.  Specifically, one study found that most medication errors were more likely to occur when the previous 30 minutes were hectic and involved staff member distraction.  It is unclear how much of a role the environment played in this case.

The hospital involved in the issue focused efforts on ensuring hospital policies were re-emphasized.  While this is a typical response in this type of situation, the training efforts must ensure that the importance of the policies is emphasized, possibly by using lessons learned from actual cases to demonstrate the risk of these policies not being followed.  Additionally, all staff must take responsibility for patient safety.  Even though the policy required repeat back by the nurse, other staff members involved with the procedure should have played a role in ensuring that the communication between members was adequate to ensure patient protection.

Want to learn more? See our webpage about medication errors in medical facilities or watch the video.


Stroke Treatment Inadequate in Many Cases

By ThinkReliability Staff

Research presented at the American Stroke Association’s International Stroke Conference 2014 showed that although 81% of people in the United States lives within an hour’s drive of a hospital equipped to treat acute stroke, only 4% received tPA, a drug which can reduce disability if given within 3-4 hours of the first stroke symptom, and the only drug approved by the FDA to treat stroke.

Researchers reviewed the records of 370,000 Medicare stroke claims from 2011.  (Annually in the United States, 800,000 people suffer from stroke.)  The low percentage of patients receiving the recommended (and only) treatment for stroke is a significant impact to both the patient safety goal (because of the disability that could be avoided with proper treatment) and the patient services goal, because so many patients are not getting adequate treatment after a stroke.

There are many challenges involved in administering tPA within the recommended time frame.  Administration is ideally done within 3-4 hours of the first stroke symptoms, but faster is better.  As the study‘s lead author, Dr. Opeolu Adeoye, M.D., M.S. states, “Every 15-minute delay in getting treatment increases the odds of that patient not being able to go home.”

Although 4 out of 5 patients live within an hour’s drive of a designated stroke center, a hospital which is equipped to treat stroke (and not all hospitals are), that still leaves almost 20% who aren’t.  The drug tPA can’t be administered before imaging confirms the stroke and that it is a non-bleeding-type stroke as administering tPA to patients suffering from a bleeding-type stroke can cause harm.  Even after a patient arrives at a stroke center, delays in imaging and treatment could increase the time before tPA is administered to outside the window.  The study also found that 60% of hospitals did not administer tPA to stroke victims, though it is the only recommended treatment for acute stroke.

Many potential solutions are being studied and implemented to reduce the risk of stroke after disability.

For patients: the best way to reduce the risk of disability from stroke is to prevent having a stroke in the first place.  About 80% of strokes are preventable and due to risk factors, such as smoking or obesity.  Maintaining a healthy lifestyle can reduce the risk of stroke.  If you or a loved one suffers from a stroke, contact an ambulance, as the ambulance will be able to direct you to a designated stroke center.  If you are driving yourself, it’s worth it to go to a designated stroke center, even if that means “bypassing another hospital that isn’t set up to deliver the necessary therapy, ” says Dr. Adeoye.

For paramedics: because paramedics tend to see most stroke patients before they get to a medical center, the search is on for a drug that could be administered prior to imaging (unlike tPA) so that stroke treatment could begin prior to arriving at a medical center.  A study looked at administering intravenous magnesium in the ambulance, but found that it did not improve stroke-related disability.  However, if another drug can be found that would, researchers are hopeful, as the median time for receiving the stroke treatment by ambulance was 45 minutes after symptoms began, and 74% of patients began treatment within an hour.

For medical centers:  The American Heart Association/ American Stroke Association’s national quality initiative Target: Stroke℠ aims to reduce the time between stroke symptoms and treatment.  Since its initiation in 2010, the percentage of patients treated within 60 minutes or less from hospital arrival has increased from less than one-third to more than one-half.  Additionally, the average time from arrival to treatment dropped from 74 to 59 minutes. These faster treatment times have reduced the percentage of stroke patients who died in the hospital from 9.9% to 8.3%.  The improvements were seen in patients regardless of age, sex, or race.

Ideally, the implementation of these solutions – and many more that are in the works – will continue to reduce the risk of, and from, stroke.

To view the Outline, Cause Map and solutions related to inadequate treatment for stroke patients, please click “Download PDF” above.  Or click here to read more.

Concern about Quality of Medical Care for Inmates

By ThinkReliability Staff

Those in the custody of law enforcement are almost completely dependent upon law enforcement for their basic needs.  One of these needs that is not always being met involves proper medical care, or even checks after the declaration of a medical emergency.   Per Dr. Ronald Shansky, a physician who performs court-ordered monitoring of inmate conditions for Milwaukee County, Wisconsin, failure to provide proper medical care is a failure to uphold constitutional obligations to those in custody.  After all, he says, “The inmate is completely dependent.  Unless the system creates the opportunity for the medical tests to be done, the medications to be provided, it’s not going to happen.”

In Milwaukee County, which was the subject of a recent investigative report by the Milwaukee Journal Sentinel, 18 people died in the custody of law enforcement in the county between 2008 and 2012.  Of these deaths, 10 were found to be related to improperly treated or monitored conditions.  By performing a detailed investigation of just one of these deaths, solutions that could reduce the risk of all custodial deaths due to improperly treated or monitored conditions can be incorporated.

We can perform this investigation by creating a Cause Map, or visual root cause analysis.  We begin with the specifics of one of the 10 cases of custodial death.  For this example, we’ll look at the death of Jeremy Cunningham.  Mr. Cunningham died the morning of June 22, 2011, while he was being held at the Milwaukee Secure Detention Facility for violation of parole.  Two important factors to note were that the inmate reported that he had alcohol and drugs in his system (taken within 8 hours) and that the inmate had a heart condition.

Next we determine the impact to the goals from the perspective of the Department of Corrections.  The inmate safety is impacted due to the death of a person in custody. Because of the constitutional obligation of law enforcement to care for those within their custody, the compliance goal is impacted.  Additionally, due to the insufficient treatment of the victim while in custody, the inmate services goal was impacted.

Beginning with the inmate safety goal, we can ask why questions to determine the causes of the impact to the goal.  The patient died because of a health issue that was not sufficiently treated.  Though the autopsy determined that the inmate died from cocaine poisoning, a pathologist who reviewed the results believes that alcohol withdrawal is more likely.  Because the cause of death is still under debate, we can use a “?” to indicate that it is not yet known (and more evidence is needed to determine the actual cause of death, though this is unlikely to occur).

Had the patient experienced the health issue but received treatment, he would have been less likely to die as a result.  Thus, the insufficient treatment from the prison staff is a cause of his death.  From available information, several opportunities were missed to assess the inmate’s health needs.  In other cases involving inmate deaths, an expectation of 30-minute check of prisoners is discussed, though it appears that requirement is not frequently being met.  This is likely because of chronic understaffing due to funding issues.  Even after the inmate’s roommate pressed the emergency call button when the inmate begin seizuring, nobody was sent to check on the condition of the inmate. (The emergency call button was pressed during the night, and the inmate was found dead in the morning.)  At the time of the death, there was no policy in place specifying what to do upon receipt of an emergency call, though the alcohol withdrawal instructions state that an ambulance should be called if an inmate experiences seizures.

Although the inmate had reported use of alcohol and cocaine within 8 hours before his incarceration, he was not monitored for withdrawal symptoms, although nurses had indicated monitoring was necessary.  Additionally, the prisoner did not receive any special care or instructions due to his heart condition.  It’s possible his heart condition wasn’t known – he died within 20 hours of entering the facility, which does not have an on-site medical practitioner, and prison medical records are delivered within 24-48 hours.

The failure of the system to provide adequate care to this inmate, as well as the 9 others who died in custody due to failure of monitoring or treatment has led to some changes being adopted by the Department of Corrections.  (Other changes are being forced by the legal system.)  These include posting notices on the doors of inmates who need extra attention, analyzing blood alcohol content upon arrival, and requiring an in-person evaluation to   respond to all emergency calls from within the prison. Hopefully these changes will reduce the failures that led to Mr. Cunningham’s death as well as some of the other deaths.

To view the investigation of Mr. Cunningham’s death, as well as a timeline outlining all 18 deaths in Milwaukee County law enforcement custody, please click “Download PDF” above.  Or click here to read more.

Norovirus Outbreak on Cruise Ship Sickens Over 600

By Kim Smiley 

A cruise ship has once again made national headlines for a negative reason.  A norovirus outbreak on Royal Caribbean’s Explorer of the Seas sickened nearly 700 hundred people during a cruise that ended on January 29, 2014.  Noroviruses are extremely unpleasant and cause extreme stomach cramps, vomiting and diarrhea, not exactly the stuff fantastic vacation memories are made of.  According to the Centers for Disease Control and Prevention (CDC) there have been 56 gastrointestinal outbreaks on cruise ships in the past five years, but this outbreak is notable because it was one of the largest in 20 years.

This incident can be analyzed by building a Cause Map, a visual format for performing a root cause analysis that intuitively shows the cause-and-effect relationships between the causes that contribute to an issue.  A Cause Map is built by asking “why” questions and documenting the answers. ( To view a high level Cause Map of this example, click on “Download PDF”.)

In this example, the initial source of the norovirus is not known and may not be able to be determined, but a Cause Map can still be helpful in understanding how the outbreak spread and how the outbreak impacts the goals of the company.  The CDC did investigate the outbreak, but it can be difficult to determine how the norovirus was brought onboard.   Noroviruses are common, especially during the January through April peak season for norovirus infections, and cruise ships need to have a plan to deal with sick passengers because simply preventing a norovirus from coming onboard isn’t realistic.

Once a person infected with a norovirus is onboard a cruise ship, the illness can spread quickly because is highly contagious.  Noroviruses can be transmitted by contact with an infected person, consuming contaminated food and even touching contaminated surfaces such as stair handrails.  Cruise ships, along with other confined spaces such as nursing homes, are particularly susceptible to fast spreading outbreaks of norovirus because there is a large number of people in a small space and it can be a challenge to isolate sick people.  Many cruise ships also serve meals buffet style which can pass the virus quickly to a large number of people.

The cruise ship did have a plan in place to help mitigate any outbreaks and the number of ill passengers was decreasing by the time the ship returned to port.  Sick passengers were isolated to their cabins and crew increased cleaning and sanitation of the ship during the cruise.  The ship was also given an especially thorough cleaning and extra sanitizing prior to departure of the next cruise.  In order to track and help cruise ships prevent outbreaks the CDC also runs a Vessel Sanitation Program, which monitors illness at sea and provides information about disease prevention.  If plan to take a cruise, the best way you can protect yourself is by frequently and thoroughly washing your hands with soap and water.

Visit our previous blogs if you are interested in learning more about other cruise ship examples:

Engine Room Fire Results in Cruise Ship Nightmare

Cruise Ship Loses Power

The Salvage Process of Costa Concordia