Risk Management in healthcare settings
On July 18, 2006, my daughter Robin was admitted to the hospital. She was 24 years old, and she was 35 weeks pregnant. She was admitted for intractable pain, vomiting, and dehydration.
It wasn’t the first time Robin had been admitted to the hospital. She had had episodes with similar symptoms from the time she was 11 or 12 years old. She would have intense abdominal pain and would start vomiting. She would vomit 30 times a day. She would get dehydrated, of course, and so we would have to admit her to the hospital. The first summer it seemed like she was in the hospital every other week. The doctors finally decided it was an autoimmune syndrome that they had seen mostly in teenaged girls, and they just grow out of it. We tried allergy-type treatments, which never seemed to work, and in the end they decided that the only way they could treat it was symptomatically.
When she would get sick she would be admitted to the hospital and given intravenous fluids, and she would essentially take nothing by mouth until her stomach settled down and she could tolerate food again. She didn’t get sick because of the nausea; she got sick from the pain and responded to narcotics. They would give her prednisone because of the allergy reaction, and they would hydrate her. And that’s what we did for several years. As she got older, the episodes got fewer and farther between. By the time she graduated from high school, she was only getting sick two or three times a year. She got married and moved away and started working for a family practice doctor who prescribed medication she could take on a regular basis. She did well on the medication, and she seemed to have things under control.
Then she got pregnant. Her medication was not compatible with pregnancy, so she had to go off it. But she did fine, even after that, until she got to 28 weeks pregnant. And then, maybe because of the size of the uterus and the body changes, she became sick again. By the time she was 32 weeks pregnant, Robin had lost about 60 pounds. They decided to put in a central venous catheter, a catheter placed in a large vein in her chest. This let her take lipids and total parenteral nutrition (TPN), so she received most of her nutrition intravenously. She continued to work. She would come home and hook up her IVs; they would run all night, and she would go back to work the next day. Whenever she did start to get sick, she would go to the emergency room. They would give her some narcotics, which was an issue for some of the nurses because they didn’t think she should get narcotics while pregnant.
During the last 3 weeks of her first pregnancy she basically quit eating and lived on ice chips, because anything she ate she threw up. They delivered her early at about 37 weeks. Jerick, my grandson, weighed 6 pounds, 4 ounces. Her weight loss hadn’t bothered him at all. He did fine.
“It’ll Be Different This Time”
Robin talked about wanting to have a little girl, and I kept discouraging her. I said, “Robin, you remember how sick you were. Do you really want to go through that again?”
Then Jerick came up to me one day and he had on a tee shirt that said, “I’m the big brother.” I looked at Robin and said, “Oh, honey, really?” She said, “Yeah, Mom, but don’t worry. It’ll be different this time.” I said, “Okay.” I was thrilled, of course, to have another grandchild, but I certainly didn’t want to see her in as much pain as before.
And again, she did well until she was 26 or 27 weeks along and then she became sick. Robin’s younger sister was getting married in June, and toward the end of May, Robin’s doctor, who was also the doctor that she worked for, wanted to put in a peripheral intravenous central catheter (PICC) running from an IV site in her arm to the large blood vessel above the heart to restart the intravenous nutrition. Robin didn’t want to have a PICC line because she didn’t want it to show in the wedding pictures. So she made him wait until the wedding was over, and about the middle of June they put in the PICC line. She began to infuse the TPN at night and continued to work during the day, just as she had done during her first pregnancy. She had probably lost 40 pounds by that time.
They did a lot of ultrasounds to make sure that the baby was growing. We found out it was going to be a girl. She was just thrilled. She had her boy and now she was going to have her girl, and this would be the end of it. She wouldn’t have to go through this again.
Jerick turned 3 on July 15 and we went to celebrate his birthday. Robin was very sick. I talked her into letting me take Jerick home with me so that they wouldn’t have to worry about childcare if she had to go to the hospital. So Jerick came home with me.
On the morning of July 18 Robin called and said she had gone to the hospital. She was 35 weeks pregnant, and the doctor who was taking care of her wanted her induced. He talked to the pediatrician, and the pediatrician agreed. He said, “You know, she’s 35 weeks. It’s probably just as safe for the baby to be on the outside as it is on the inside, as sick as she is now.”
Robin was excited. She said, “Mom, pack some extra clothes, because you’re going to stay and we’re going to have the baby.” We were both excited. I started driving to her hospital, but when I was about halfway there she called and she was crying. She said the OB doctor, the obstetrician who was supposed to induce her, said he would not induce her before she had completed 37 weeks due to the risk to the premature baby.
He told Robin he didn’t care how many times she got sick, that she would have to stay in the hospital until she was ready to be induced at 37 weeks as that was best for the baby. Well, that meant 2 more weeks in the hospital, without Jerick. She didn’t have any extra time left to take off from work, and it was just devastating for her to find out that they weren’t going to deliver her that day.
I arrived at the hospital about 1:00 in the afternoon. Robin was in the shower, which was not a good sign. Hot showers were the only thing she had found that helped relieve the pain, other than narcotics. She would take four or five hot showers a day whenever she was sick. Robin came out of the shower and she said, “Mom, there’s something wrong. I hurt everywhere. My feet hurt. My hands hurt. Everything hurts. And it started when they hung that bag of stuff there.” She pointed to a bag hanging on the IV pole. The only way I can describe it is to say that it looked like a melted chocolate milkshake, sort of like a protein drink. I looked at it and on every corner it said, “Not for IV Use”—and it was hooked to her PICC line, which of course is an IV. And I did not think to question it. I didn’t ask anything about it.
Robin called the nurse and asked, “Can you tell my mom what the plan is?” And the nurse said, “Well, we have started her TPN and we are going to keep her in the hospital until she’s 37 weeks and wean her off the narcotics because we think that’s what is wrong with her. She is getting too many narcotics.”
I was a little dubious but I said, “Okay, if that’s what we need to do, that’s what we’ll do.” But Robin was so uncomfortable. She asked the nurse why she was in so much pain and the nurse said, “Well, it’s because we are not giving you as much pain medicine. You’re just anxious and you need to relax.” She got her some Vistaril for anxiety. Again, I didn’t question it. I went along with them.
Robin tried to rest. She just hurt so much, but they wouldn’t give her any more pain medicine. She had been hooked up to a fetal monitor earlier that morning and the strip was still on the monitor. I looked at it, and from the tracing it looked like the baby was asleep. It wasn’t very reactive, but because Robin was on narcotics that wasn’t surprising. This was another reason the nurse had said that they wanted to keep Robin in the hospital, because the baby’s fetal monitor strip wasn’t reactive, even though it obviously wasn’t going to be if Robin was on narcotics. But again, I didn’t question it.
“You’ve Got to Fix Me”
I had dropped Jerick off at daycare before coming to the hospital, but I had to pick him up at 5:00 p.m. I told Robin, “I’ve got to go pick up Jerick, but I’ll be back when Jeremy gets home from work.” I got Jerick and went to their house. I was waiting for Jeremy to get home, when Robin called. She said, “Mom, I need you to come back. They’ve done something wrong.”
I called Jeremy and said, “You need to come home now. They’ve done something at the hospital and we need to go back there.” I got to the hospital about 6:00 p.m. When I walked in the room Robin was on a heart monitor and she had on a facemask with oxygen. She looked at me, and tears just rolled down her cheeks. She said, “Mom, I’m so scared.”
I said, “It’ll be okay. They’re going to take good care of you. We just need to take care of you.” But when I put my hand on her back, you could feel and hear, whenever she breathed, the fluid that was in her lungs.
The nurse came in. I asked her, “Have they checked on the baby?”
She said, “Yes, we ran a fetal monitor strip a while ago. The heart rate was 150.” But on the monitor Robin’s heart rate was also 150. I’m sure they were picking up Robin’s heartbeat rather than the baby’s. They should have checked Robin’s pulse to make sure. But 150 is a very common baby heart rate, and they just took it at face value.
The OB doctor came in about then. He said, “Robin, I think they gave you too much fluid in the emergency room. We’re just going to give you some Lasix and we’ll get this taken care of.”
And he left. The nurse was still there with me. I said, “Is that all they’re going to do? Are they going to do something else? She looks terrible.”
I didn’t say that loud enough for Robin to hear. But she had a terrible color. Her oxygen saturation was 89. Her heart rate was 150. She was having trouble breathing. I said, “What else are you going to do?”
The nurse said, “We’ll get the Lasix. We’ll get that started.”
About that time Robin’s doctor came in, the one who’d been taking care of her and who she worked for. He came over, and he gave her a hug. She said, “Chief, you’ve got to fix me.”
He said, “I will, Robin. I’ll take care of you.” He asked the nurse, “How much of that stuff did she get?”
I hadn’t even noticed it when I walked in at 6:00 p.m., but the brown-looking bag was not hanging on the pole any more. She just had a transparent saline solution hanging. The nurse showed the doctor on the computer how much of the brown-looking solution she had been given. He said, “Okay.” He ordered Robin more Lasix, and he wanted her to have BiPAP (bilevel positive airway pressure) to help improve her breathing. So the respiratory technician came down and hooked up the BiPAP. She started feeling better. Her oxygen saturation came up to around 93% and she felt more comfortable.
The OB doctor came back in. He said, “Let’s check on the baby.” He listened for a while and he didn’t hear anything. He said, “Let’s get the ultrasound.” He looked with the ultrasound for a while and he didn’t say anything. I looked at it and I didn’t see the baby’s heartbeat. I could see the baby, because I have looked at a lot of ultrasounds, but I didn’t see a heartbeat.
He said, “We need to get the big ultrasound machine down here, to really take a look.” And he left.
I walked outside the room. The nurse came out. I asked her, “Did you see a heartbeat?”
The nurse said, “Well, you know, it’s not a very good ultrasound machine. It just basically tells us the position of the baby. We’re going to get the big machine down here to look again.” I said, “Okay.”
So they got the big ultrasound machine, and the OB doctor sat at the foot of her bed and he looked for a while. Robin watched the monitor and then she looked at me and she said, “Mom, is she dead?” I said, “Yes, Robin, I believe she is.”
And I said, “But we can deal with that, Robin. We just need to take care of you right now.” The OB doctor said, “That’s right, Robin. You just need to listen to your mom.” And he left. He never said anything about the baby or the lack of heartbeat.
A Higher Level
A short time later Robin’s doctor came back in. He checked on Robin and then he said to me, “I want to talk to you out in the hall.”
I went out into the hall with him. The OB doctor was there. Robin’s doctor said, “I think we need to get her to a higher level of care. We have called LifeFlight and we’re going to transfer her. But I think it’s probably better for us to intubate her here than for them to have to do it in the helicopter.”
In my mind, I was thinking, “Okay, we lost the baby. We’ll deal with that. Robin is just going to be in another hospital for a few extra days.” It never entered my mind that she wouldn’t be okay. It just never occurred to me.
We went back in and he told Robin what they wanted to do. And she agreed that we needed to do something different. They called anesthesia to come intubate her.
About that time, her husband Jeremy arrived. Both the doctors were busy and I said, “You guys work on Robin and make sure she’s okay. I’ll go talk to Jeremy.”
I went out and I told him. I said, “Jeremy, the baby’s dead, and Robin is so sick that they’re going to transfer her. LifeFlight is on its way and they’re going to send her out.”
I stayed with him a little bit, and then headed back to Robin’s room. They stopped me outside the door and said, “You can’t go in there.”
I said, “That’s my daughter in there! I can go wherever I want. I’m going back in there.”
They said, “No, you can’t go back in there.”
I could hear through the door that they were talking about bicarb and epinephrine, and I knew they were coding her. The head nurse came out; I think she was coming out to get something. I stopped her and said, “You guys need to come out here and tell me what is going on. Somebody needs to come out and tell me now.”
They took us down to a little room down the hall. They said, “Somebody will come in and talk to you.”
Robin’s doctor came in. He said, “Well, we’ve called a cardiologist to come in, but he’s not in house. He’s on his way in.”
They had put in a pacemaker. Without the pacemaker, her heart rate was a slow 30. Even with the pacemaker, they weren’t getting any peripheral pulses, so her heart was not pumping enough blood to her brain.
I told him, “Okay, stop. Stop right now. You cannot be talking about one of my girls that way. You need to get back in there and you need to fix her, because this cannot be happening.”
He left. He was gone for a few minutes. He came back in and he opened the door. I looked at him and I just turned my back on him.
I said, “Can you keep her alive until her sisters get here to say good-bye?”
He said, “No, I don’t think I can.”
I said, “I want to see her.” They pronounced her dead at 8:36 p.m., 3 days after Jerick’s third birthday.
A Tubing Misconnection
The nurse had erroneously given Robin an enteral feed, a thick mixture like a nutritional shake, in her intravenous PICC line. Enteral solution is suitable only for feeding via the gastrointestinal tract, usually through a feeding tube. This error ultimately caused the death of Robin and the baby.
The origin of the error was a little mysterious. A bag of enteral feed with Robin’s name on it had been delivered to the unit. The delivery came from the dietary department, because enteral feed was considered a food at that hospital and was dispensed through the dietary department. The total parenteral solution (TPN) that Robin was supposed to have received was considered an IV medication and would have come from the hospital pharmacy. To complicate matters, the hospital had just introduced a new computer system, and they still were hand-writing orders for the secretary to put into the computer. The order for the enteral feeding bag was time-stamped and name-stamped by the unit secretary, but the secretary said she had not put the order in. There were no written physician orders for either the enteral solution or the TPN.
The hospital policy was that two nurses check the label and the ingredients against the order before it was given to the patient. But in this case there was no order, and the nurse did not have a second nurse check it with her and did not scan the bar code on the medication. The nurse knew that the plan was for Robin to get TPN, so that’s what she assumed the bag was, even though it looked nothing like TPN.
Typically, a bag of enteral solution comes from the manufacturer attached to a tube that will only fit a feeding tube, not an IV. But not all manufacturers make it that way. In Robin’s case, the bag came without tubing. So the nurse got some IV tubing off the shelf, spiked the bag with the tubing, and put the tubing on an IV infusion pump. The enteral solution was too thick to run on its own, so the nurse set the infusion pump to 200 mL an hour and connected it to Robin’s PICC line. A PICC line sits right at the arch of the aorta, so the feeding was dumping right into her heart, and it had such a high fat content that everything was clogging up. That’s why her feet hurt so much, because all the little vessels in her feet—everything—were just clogging up with fat.
The policy at the hospital was that the nutritionist would see every patient before the patients were started on TPN. The nutritionist was going through the charts and the nurse said, “We’ve got the TPN started.” This in itself was a policy violation. The nutritionist said, “No, she’s not on TPN; there’s no order for it.” It was then that they noticed the mistake. The enteral feeds were started at 11:00 a.m. and they were stopped around 5:00 p.m. The nurse never realized there was anything wrong until that moment.
The nurse lost her job at the hospital and surrendered her license under a plea agreement that allowed her license to be reinstated after 8 months. When she got her license back, she went to work for the OB doctor involved in Robin’s case.
The hospital administration started using the closed tubing system so nurses did not have to attach the tubing, and they made enteral feedings the responsibility of the pharmacy rather than the dietary department, so that a licensed healthcare professional would be checking the orders. They also did a lot of education to try to make their nurses aware of tubing misconnections.
I started talking about tubing misconnections to everyone I could get to listen. I have been part of an international group working on new standards, but change is coming much more slowly than I would like. As a nurse, I have changed my practice about patients and families asking questions. I know that sometimes it can feel as though families are questioning your ability and authority. But if there is something that doesn’t look right, families should ask the question. If the nurse sees something that doesn’t look right, the nurse should question it. If you don’t get a good answer, question it again. Keep questioning until you get a resolution. I will go to my grave wishing that I had done that for Robin and Addison.
Discuss the chain of events and mistakes that led to the death of Robin and her baby. At what point could the pending disaster have been stopped? What processes could be put in place to prevent such an event from occurring?
The most significant change that the hospital made was to stop buying enteral feeding solution that came without the tubing attached. Research human factors theory and discuss the human factors issues that arise with tubing misconnections. How can forcing functions like the anticipated move to specialized connectors improve the situation?
Glenda Rodgers blames herself for not asking more questions when her daughter was in the hospital. She feels that, as an experienced obstetrical nurse, she should have caught what was going on and been able to put a stop to it. Yet stories of healthcare professionals being unable to stop adverse events from happening to their own family members are common. Why do you think that healthcare professionals may feel helpless to prevent errors when they become a patient or have a family member who is a patient?
Research the concept of just culture, and discuss how you think it applies in this case. What should the consequences have been for the nurse who caused the tubing misconnection?
As the rollout of new tubing connector standards began, the American accrediting agency The Joint Commission issued Sentinel Event Alert No. 53 to help healthcare facilities deal with the transition. Why do you think The Joint Commission considered this to be necessary? What unintended consequences should healthcare professionals be vigilant for when changes take place in practice and technology?
Which of the core competencies for health professions are most relevant for this case? Why?