Background:
Delta Hospital is a 500-bed suburban teaching hospital. The nearest peer hospital is located almost 200 miles away. They are a level 1 trauma center, level III neonatal intensive care unit and offer a wide range of specialty clinical services including interventional cardiology, general surgery, orthopedics, cancer care and emergency medicine. Through a university affiliation, the hospital co-sponsors a physician residency program through which an average of 15 medical school graduates complete their medical or surgical residencies each year. Such residency programs require rotations in many areas, including emergency medicine facilitated through a very active emergency department.
The Case – Medical Gas-Intravenous Mix-up:
A four-year-old patient is brought to the emergency room by his parents for an apparent upper respiratory infection and dehydration. The nurse sees the patient immediately and the child is quickly set-up in an emergency room bed. A history and physical confirms a diagnosis of upper respiratory infection and a right lower lobe pneumonia. Additional laboratory tests are ordered and the patient is started on oxygen, inhaled medications (bronchodilators), antibiotics and intravenous fluids.
Remote monitoring is initiated for heart rate, respiratory rate, blood pressure, and pulse oximetry-blood oxygen levels. After inserting an intravenous catheter, the nurse briefly leaves the room to obtain intravenous tubing. While the nurse is out of the patient room, a first-year (new) resident physician (in-training) enters the room and proceeds to erroneously connect the oxygen tubing (which gas oxygen running through it) rather than intravenous tubing (which is for fluids) to the intravenous catheter, resulting in a massive gas embolism (air/gas bubble in the vein). The patient quickly loses consciousness and after multiple attempts to resuscitate him, dies.
Questions: Review the case within the context of Chapters 10 and 11 of the Nash text, and then address all four of the following questions, using and citing at least two outside sources.
As defined by The Joint Commission, what is a sentinel event and why would you or would you not characterize this as one?
Was this medical error mainly the result of an incompetent physician resident which could be addressed by simply firing them? Or, was the problem the result of a series of actions which occurred in the context of a flawed process or system, requiring a careful analysis and remediation plan?
If this was a problem of a flawed system or process, identify at least three facets of the process or system which may have contributed to the problem. Optimally, use and submit with your response, a fish-bone diagram to illustrate the primary and related secondary factors which may have contributed to the occurrence of this error.
Describe in some detail the major elements of the remediation plan which could be used to help minimize the likelihood of this type of error reoccurring.
