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.