Case Study 3


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Case Study 3

  1. 1. Patient Safety Training “ Error Free Patient & Site Identification” Partners Radiology Patient Safety Team
  2. 2. Goal “ Improve patient safety by providing tools to assess staff competency in error free patient and site identification”
  3. 3. Objectives <ul><li>At the end of the training the participant will be able to: </li></ul><ul><ul><li>Identify how errors occur (causes) </li></ul></ul><ul><ul><li>Identify effects of errors on patient, department and hospital </li></ul></ul><ul><ul><li>Discuss countermeasures </li></ul></ul><ul><ul><li>Define & deploy the hospital specific patient identification process </li></ul></ul><ul><ul><li>Understand how to employ various methods for competency assessment </li></ul></ul>
  4. 4. Methodology <ul><li>Blame-free Approach – Share incidents, policies, procedures and risk reduction strategies employed </li></ul><ul><li>Failure Modes & Effects Analysis Approach (FMEA) - Identify true cause and effects of sentinel and adverse events and proactively prevent such high-risk events from occurring by implementing selective countermeasures. </li></ul><ul><li>Root Cause Analysis – Analyze adverse and sentinel events retrospectively to identify failures in systems and processes </li></ul>
  5. 5. Target Audience <ul><li>All clinical and non-clinical personnel involved in the patient & site identification process - Technologists, MDs, RNs and Support Staff </li></ul>
  6. 6. Case Study 1 Correct patient/Incorrect chart Non-compliance with patient identification procedure
  7. 7. Case Study 1 <ul><li>Mr. Chen in room 426A has been ordered for a biliary drainage tube. </li></ul><ul><li>Transport is called to bring down Mr. Chan in 428A for an abdominal CT scan. </li></ul><ul><li>15 minutes later, transport is called to bring patient in 426A. </li></ul>
  8. 8. <ul><li>The patient is brought to interventional radiology. </li></ul><ul><li>The nurse and tech review the chart for Mr. Chan and confirm the written MD order for the biliary procedure. </li></ul><ul><li>During the consent process the patient appears to understand, nods his head in agreement and signs the consent. </li></ul>Case Study 1
  9. 9. <ul><li>The procedure progresses with no complications up until the guide wire is removed. As the guide wire is removed, it is followed by a large gush of arterial blood. </li></ul><ul><li>Surgical consult is immediately called and patient is rushed to the OR for emergency surgery of his hepatic artery. </li></ul>Case Study 1
  10. 10. <ul><li>Meanwhile in CT, Mr. Chen is asking when his biliary tube placement is scheduled for? </li></ul><ul><li>The CT tech calls interventional radiology and asks when Mr. Chen is scheduled for his biliary drainage tube. </li></ul><ul><li>The interventional tech replies, “We just finished the biliary drainage tube placement. I better call you back”. </li></ul>Case Study 1
  11. 11. What happened? Case Study 1
  12. 12. What happened? <ul><li>Two patients with similar names on same floor </li></ul><ul><li>Transport called for patient by room number only </li></ul><ul><li>Secretary/Unit coordinator gave transport incorrect information due to similarity of names </li></ul><ul><li>Patient was addressed by procedure name </li></ul>Case Study 1
  13. 13. <ul><li>Language barrier not recognized during rush to consent patient </li></ul><ul><li>Disregard for policy – no one verified name and date of birth with patient chart </li></ul><ul><li>Disregard for policy – no one verified written order and patient’s armband </li></ul>What happened? Case Study 1
  14. 14. Effects <ul><li>Patient exposed to unnecessary invasive radiology procedure, which resulted in complications (PE) </li></ul><ul><li>Patient almost died (PE, RE, HE) </li></ul><ul><li>Increased length of stay/ICU stay (HE) </li></ul><ul><li>Malpractice liability (HE, RE) </li></ul><ul><li>Patient inconvenience & decrease in patient confidence (PE) </li></ul>Case Study 1 PE – Patient effects; HE – Hospital effects; RE – Radiology effects
  15. 15. Effects Case Study 1 PE – Patient effects; HE – Hospital effects; RE – Radiology effects <ul><li>Delay in treatment of Mr. Chen (PE) </li></ul><ul><li>Patient care issue (RE, HE) </li></ul><ul><li>DPH review of case (HE) </li></ul><ul><li>Delay in treatment of Mr. Chan (PE) </li></ul><ul><li>Increased length of stay (HE, PE) </li></ul>
  16. 16. Countermeasures Case Study 1 <ul><li>Correct patient ID procedure – use of 2 valid patient identifiers – Active verification (Ask patient to state name and DOB) </li></ul><ul><li>Compliance with patient identification policy </li></ul>
  17. 17. Questions Case Study 1 <ul><li>Which of the following should be employed for correct patient ID using patients specific name? </li></ul><ul><ul><li>1. Call for the patient using patient’s last name only (compliance with confidentiality) </li></ul></ul><ul><ul><li>2. Ask the patient to state their first and last name </li></ul></ul><ul><ul><li>3. State to the patient “ Your name is….” </li></ul></ul><ul><ul><li>4. Provide hospital interpreter service and/or arrange for legal guardian </li></ul></ul>
  18. 18. Questions Case Study 1 <ul><li>Which of the following could be employed for a second patient identifier? </li></ul><ul><ul><li>1. Patient’s DOB </li></ul></ul><ul><ul><li>2. MRN </li></ul></ul><ul><ul><li>3. Referring physician's name </li></ul></ul><ul><ul><li>4. Date of last exam </li></ul></ul><ul><ul><li>5. Patient location or room number </li></ul></ul>
  19. 19. Wrong patient scheduled by physician’s office Case Study 2
  20. 20. <ul><li>Melanie Murphy, 45 year old female, arrives at Dr. Feel Good’s office. Dr. Feel Good instructs the secretary to order a CT study for Ms. Murphy. The harried secretary quickly schedules the exam and sends the patient to Radiology. </li></ul>Case Study 2
  21. 21. <ul><li>Upon Ms. Murphy’s arrival in Radiology, the receptionist confirms the patient name, checks her in and enters the requisition for Melanie Murphy. </li></ul><ul><li>On receiving the requisition, the technologist goes to the waiting room and calls for Melanie Murphy. </li></ul>Case Study 2
  22. 22. <ul><li>Ms. Murphy stands up and follows the technologist to the exam room. The technologist confirms the patient name and referring physician’s name and completes exam. </li></ul><ul><li>Subsequently, Melanie Murphy goes for a follow-up visit to Dr. Feel Good’s office and the doctor discovers that he has not received any report for the exam in the system. </li></ul>Case Study 2
  23. 23. What happened? Case Study 2
  24. 24. <ul><li>Referring MD’s secretary entered the wrong exam information – incorrect DOB and/or MRN </li></ul><ul><li>Radiology receptionist confirmed patient ID with one identifier – “patient name” </li></ul><ul><li>RT used one valid form of ID (patient name) and one invalid form of ID (referring MD’s name) </li></ul><ul><li>Referring MD did not use an ID specific only to that patient – made an order based on patients name only </li></ul>What happened? Case Study 2
  25. 25. <ul><li>Patient inconvenience (PE) </li></ul><ul><li>Decrease in patient satisfaction/confidence (PE) </li></ul><ul><li>Correct patient did not get results (PE & RE) </li></ul><ul><li>Delay in diagnosis (PE & RE) </li></ul><ul><li>Wrong patient billed – Medicare fraud (PE, RE & HE) </li></ul><ul><li>Revenue loss (RE & HE) </li></ul>Effects Case Study 2 PE – Patient effects; HE – Hospital effects; RE – Radiology effects
  26. 26. <ul><li>Exam results sent to wrong patient chart – HIPAA violation (PE, HE & RE) </li></ul><ul><li>Decrease in MD satisfaction (RE & HE) </li></ul><ul><li>Litigation issue (RE & HE) </li></ul><ul><li>Patient care issue (RE & HE) </li></ul><ul><li>Compliance issue – Medicare Fraud/HIPAA violation (RE & HE) </li></ul>Effects Case Study 2 PE – Patient effects; HE – Hospital effects; RE – Radiology effects
  27. 27. Countermeasures <ul><li>Ordering physician should confirm orders </li></ul><ul><li>Secretary in office should verify two forms of patient ID (Patient name & DOB) </li></ul><ul><li>Radiology receptionist should verify two forms of patient specific identification (JCAHO specific) </li></ul><ul><li>RT should verify two forms of patient specific identification (JCAHO specific) </li></ul>Case Study 2
  28. 28. Case Study 2 Questions <ul><li>True/False </li></ul><ul><li>Physicians are not responsible for correctly identifying patients. </li></ul><ul><li>Technologist does not need to identify patient as long as the radiology receptionist has done so. </li></ul><ul><li>The radiology receptionist does not need to verify the patient’s DOB as long as their name is on the schedule. </li></ul>
  29. 29. Results sent with wrong patient name Case Study 3
  30. 30. <ul><li>It is a hectic day in ultrasound. There are multiple ultrasound guided biopsies scheduled. </li></ul><ul><li>The unit coordinator has prepared the needed paperwork for the procedures. She affixes patient labels to unused specimen containers. </li></ul>Case Study 3
  31. 31. <ul><li>Mr. Robinson with metastatic colon cancer arrives in ultrasound and is brought into room 1. </li></ul><ul><li>Mr. Smith also arrives for his core liver biopsy and is brought into room 2. </li></ul><ul><li>Both patients’ core liver biopsies are performed after correct patient identification and time out. </li></ul>Case Study 3
  32. 32. <ul><li>The nurse in room 2 realizes that there is no specimen container in the room. The MD has the specimen ready, so the nurse rushes from the room. </li></ul><ul><li>She sees one container labeled on the counter and retrieves it. The MD then deposits the specimen into the container. The specimens for Mr. Smith and Mr. Robinson are then sent to the lab. </li></ul>Case Study 3
  33. 33. <ul><li>The pathology report for Mr. Robinson returns as benign fatty liver. The report for Mr. Smith unfortunately shows malignant metastatic disease. </li></ul><ul><li>Mr. Robinson is discharged and is scheduled for a 6-month follow-up liver scan. </li></ul>Case Study 3
  34. 34. <ul><li>While in the hospital, a course of treatment is planned for Mr. Smith and treatment includes a combination of chemotherapy and radiation therapy. </li></ul><ul><li>During the course of his treatment, he becomes immunosuppressed and develops serious MRSA pneumonia, from which he succumbs. </li></ul><ul><li>  </li></ul>Case Study 3
  35. 35. <ul><li>On autopsy it is noted that Mr. Smith had a fatty liver but no evidence of ever having liver metastasis. </li></ul><ul><li>Mr. Robinson returns prior to his 6-month follow-up with severe abdominal pain, jaundice, increased bilirubin count and fever. CT and Ultrasound exams confirm multiple large liver lesions, lymphadenopathy and ascites. Palliative treatment and hospice care are initiated. </li></ul>Case Study 3
  36. 36. What happened? Case Study 3
  37. 37. <ul><li>Neither the MD nor the RN verified patient identification on label of container versus patient identification on band and requisition. </li></ul><ul><li>Lab failed to verify patient identification on requisition with label on container. </li></ul>What happened? Case Study 3
  38. 38. <ul><li>Patient inconvenience (PE) </li></ul><ul><li>Decrease in family confidence (PE) </li></ul><ul><li>Delay in treatment leading to death (PE, HE) </li></ul><ul><li>Correct patient did not get results (PE, RE) </li></ul><ul><li>Non-traceable specimen (PE, RE) </li></ul><ul><li>Decrease in MD satisfaction (HE) </li></ul>Effects PE – Patient effects; HE – Hospital effects; RE – Radiology effects Case Study 3
  39. 39. <ul><li>Litigation issue (HE) </li></ul><ul><li>Patient care issue (PE, HE) </li></ul><ul><li>Compliance issue (HE, RE) </li></ul><ul><li>Wrong patient billed (HE, RE, PE) </li></ul><ul><li>DPH review of case and bad publicity (HE) </li></ul><ul><li>Pain and suffering for both patient and their families (PE) </li></ul>Effects PE – Patient effects; HE – Hospital effects; RE – Radiology effects Case Study 3
  40. 40. Countermeasures Case Study 3 <ul><li>Technologist needs to verify all items related to care of patient – label of container, requisition and arm band </li></ul><ul><li>Lab needs to follow correct patient identification process </li></ul><ul><li>Nurse or Technologist should assure all proper equipment is in the room before procedure starts </li></ul>
  41. 41. Questions Case Study 3 <ul><li>Who was responsible for verifying that the label ID was correct? </li></ul><ul><ul><li>Unit coordinator </li></ul></ul><ul><ul><li>RN </li></ul></ul><ul><ul><li>RT </li></ul></ul><ul><ul><li>Radiologist </li></ul></ul><ul><ul><li>Receiving personnel in lab </li></ul></ul>
  42. 42. Case Study 4 Wrong side entered in requisition Original images misread/mislabeled /incorrect report Failure to follow site verification process
  43. 43. Case Study 4 Mr. Peter Van Don, a 60 year old male patient with peripheral vascular disease and bilateral renal artery stenosis was referred by his nephrologist to a radiologist for angiography and possible stenting of the left renal artery.
  44. 44. Case Study 4 The patient was scheduled for his procedure in the usual fashion, which was later cancelled by the patient himself. In the process of rescheduling the patient, the radiologist rescheduled the patient but not in the radiology scheduling system.
  45. 45. Case Study 4 When the patient arrived for his appointment, he did not appear on the radiology schedule and the procedure team was not expecting him. The only information about the patient was on a procedure planning board. This information included “Renal arteriogram/Stenting”. He was treated as an add-on.
  46. 46. Case Study 4 The radiologist who rescheduled the procedure was not present on this morning to present the patient’s history at the morning rounds but was expected to perform the procedure later in the day.
  47. 47. Case Study 4 One of the fellows was dispatched to the floor to obtain consent. He obtained a history from the patient and wrote a pre-procedure note indicating that the patient has left renal artery stenosis: plan procedure angiogram/stenting. The consent form was signed by the patient but did not indicate which renal artery would be involved.
  48. 48. Case Study 4 The original radiologist who planned to do the procedure needed to leave at 4pm and signed out the procedure to the on call radiologist. He provided a verbal report that the patient had a stenotic renal artery and needed an angiogram and possible stenting; he did not specify a side.
  49. 49. Case Study 4 By the time the patient was called to the procedure room the fellow who had obtained consent was scrubbed in another procedure. The pre-procedure note, consent form and nursing assessment were in the patient’s medical record and brought into the procedure room along with the patient.
  50. 50. Case Study 4 The nurse’s assessment and the nephrologist’s progress note stated that the patient was here for left artery arteriogram and stent and the right kidney was not salvageable.
  51. 51. Case Study 4 The on call radiologist and the new fellow assigned to this procedure did not review the documents in the chart prior to the procedure and did not review MRA as the computer had crashed and they did not want to reboot it.
  52. 52. Case Study 4 Under direct visualization in the arteriogram, the left renal artery could not be visualized but stenosis was noted in the right renal artery. The radiologist believed that the right renal artery was the one requiring treatment and proceeded with stenting and opened blood flow to the unsalvageable kidney.
  53. 53. Case Study 4 After completing the procedure, the tech asked the radiologist “Are we going to go on and treat the left renal artery”. The patient overheard this and commented “You mean you placed the stent in my right renal artery?
  54. 54. Case Study 4 The radiologist acknowledged this and then the patient commented in a fury “ But you were supposed to treat the left renal artery, my right renal artery is not functioning”. The patient then refused any further treatment and signed himself out of the hospital.
  55. 55. What happened? Case Study 4
  56. 56. What happened? Case Study 4 <ul><li>The stent was placed in the wrong renal artery </li></ul><ul><li>Left kidney renal insufficiency was left untreated, resulting in inability to perform its function </li></ul>
  57. 57. Case Study 4 What happened? <ul><li>Patients medical record not reviewed prior to procedure </li></ul><ul><li>Failure to follow site verification process </li></ul><ul><li>Prior images were not reviewed prior to the procedure </li></ul>
  58. 58. <ul><li>Left renal artery stenosis left untreated (PE) </li></ul><ul><li>Patient inconvenience and loss of patient confidence (PE) </li></ul><ul><li>Patient exposed to unnecessary radiation and invasive procedure (PE) </li></ul><ul><li>Interruption and delay in treatment of life threatening condition (PE) </li></ul>Case Study 4 Effects PE – Patient effects; HE – Hospital effects; RE – Radiology effects
  59. 59. <ul><li>Litigation issue (HE & RE) </li></ul><ul><li>Patient care issue (HE & RE) </li></ul><ul><li>Compliance and billing issue (HE) </li></ul><ul><li>Cause of sentinel event (RE) </li></ul><ul><li>Bad publicity (HE) </li></ul><ul><li>High risk of morbidity and mortality (HE, RE & PE) </li></ul>Case Study 4 Effects PE – Patient effects; HE – Hospital effects; RE – Radiology effects
  60. 60. Case Study 4 Countermeasures <ul><li>All available documentation needs to be reviewed including prior medical imaging </li></ul><ul><li>The time out should be followed accurately – “Technologist did not speak up in this case” – If there is any question on the part of any participating personnel, everything must stop until discrepancies are sorted out </li></ul>
  61. 61. Case Study 4 Questions <ul><li>Whose responsibility was it to speak up during team pause? </li></ul><ul><ul><li>Radiologist </li></ul></ul><ul><ul><li>Fellow </li></ul></ul><ul><ul><li>Technologist </li></ul></ul><ul><ul><li>RN </li></ul></ul>
  62. 62. National Patient Safety Goals 2004 - 2005 <ul><li>Goal # 1 - Improve the accuracy of patient identification </li></ul><ul><ul><li>- Use at least two patient identifiers (neither to be the patient’s room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing or providing any other treatments or procedures (Scored at PC.5.10, EP 4) </li></ul></ul>
  63. 63. <ul><li>Goal # 4 - Eliminate wrong-site, wrong-patient, wrong-procedure surgery </li></ul><ul><ul><li>- Use a pre-op verification process, such as a checklist, to confirm appropriate documents are available </li></ul></ul><ul><ul><li>- Implement a process to mark the surgical site and involve the patient in the process </li></ul></ul>National Patient Safety Goals 2004 - 2005
  64. 64. <ul><li>Provisions of the Universal Protocol </li></ul><ul><ul><li>- Preoperative verification process </li></ul></ul><ul><ul><ul><li>Relevant pre-op tasks completed and information is available and correct </li></ul></ul></ul><ul><ul><li>- Surgical site marking </li></ul></ul><ul><ul><ul><li>Unambiguous mark, visible after prep & drape </li></ul></ul></ul><ul><ul><ul><li>Right/left, multiple structures or levels </li></ul></ul></ul>National Patient Safety Goals 2004 - 2005
  65. 65. <ul><li>Provisions of the Universal Protocol </li></ul><ul><ul><li>-“Time out” immediately before starting </li></ul></ul><ul><ul><ul><li>Involves entire team; active communication </li></ul></ul></ul><ul><ul><ul><li>Fail-safe model: “No go” unless all agree </li></ul></ul></ul><ul><ul><li>- Applicable to invasive procedures in all settings </li></ul></ul>National Patient Safety Goals 2004 - 2005