A nightmare situation yields valuable lessons

Imagine a scenario in which a patient dies from a medication error and then things just go downhill from there. As things get worse and worse, the only good thing is that you’re bound to learn something useful from the experience.

That was the situation faced by Monica Berry, BSN, JD, LLM, DFASHRM, CPHRM, regional director of risk management with SSM Health Care of Wisconsin in Madison, and past president of the American Society for Healthcare Risk Management (ASHRM) in Chicago.

She spoke on the topic at the recent ASHRM meeting in Nashville, TN. She tells a story from her own experience that illustrates how the most painful experience can yield valuable lessons.

The incident involved a diabetic patient after surgery with an order for 10 mg morphine sulfate every four to six hours. The patient was under the care of a hospitalist, who ordered a dressing change and indicated the pain medication should be given 20 minutes before. But the nurse misread the order as calling for 20 mg of the drug, and the patient ended up with an overdose and died.

The family was notified of the death and, at 5 a.m., the hospitalist called the risk manager to report that the death was caused by an accidental overdose. The risk manager cautioned the hospitalist not to jump to the conclusion that the overdose caused the death and role played with him to prepare for him for how to inform the family of the circumstances.

The hospitalist met with the family without any other hospital representative, and the charge nurse overheard him saying, "The nurse gave an overdose of pain medication and killed your mother." One of the family members became enraged and physically attacked the charge nurse, who was not the nurse in question, prompting a security response that ended with the family being escorted off the campus.

Soon after, five physicians reported to the risk manager that the hospitalist was telling everyone the nurse "killed the patient," and the family created a disturbance in medical records demanding the patient’s chart.

By 6 a.m. the next day, the risk manager was on site to gather facts and review the medical record. Upper administration was notified by 7 a.m., and an administrative huddle occurred at 8:30 a.m.

"The window of opportunity to interface with the family is lost, and the campus rumor mill is very active," Berry says. "The risk manager was called at 5 a.m., and by 7 a.m., the window of opportunity is closed. It closed very quickly and very soundly."

Berry never knew what to expect when she tried to contact the family, as each family member seemed to have a different temperament and there was no consensus on how they wished to proceed.

The situation only got worse from there — the night nurse involved in the medication error was involved in another the very next night and had to be put on administrative leave.

The nurse who was attacked by a family member had multiple sclerosis and suffered an exacerbation of the condition. She filed a workers’ comp claim and was on leave for 10 weeks, during which she was admitted to rehab.

"I simply could not have imagined a worst risk management nightmare," Berry says. "My imagination is not that good."

Failings made error possible

In addition to the inevitable lawsuit against the facility, Berry herself was sued for fraudulent concealment when her superiors ordered her not to reveal certain clinical findings to the family.

With a situation that bad, it’s nearly impossible not to learn something useful. Here’s what Berry took away from the experience:

  • Processes that are changed midstream create an opportunity for things to run amok. The modification of the physician’s orders late in the day shifted the dynamics of the work flow and the team functionality.
  • The mind sees what is expected. Human factors research refers to this phenomenon as "slips." In this case, the nurse expected to see "mg" in the second medication order just as she had in the first order. Instead, the second order actually said "mins" for minutes.
  • The night nurse was a recent graduate who was not assigned to the patient but was helping out when asked to give the medication. She thought 20 mg was a lot but justified it in her mind because of the patient’s size and was hesitant to question the order. She referred to a carbon copy of the medication order to confirm the dosage.

    "We subsequently found out that they were in the habit of using the carbon copy as their working copy of the medication order," Berry says. "Imagine the carbon copies you’ve seen that are not at all clear — smudged and blurred because they had many things stacked on them and scratched out. So you could easily see how milligrams and minutes could easily look alike."

  • The night nurse was on her first shift after orientation. She came from a long-term care setting and had no previous acute care experience. The length of time a nurse has practiced is not as important as the need for acute care experience in the past three to five years, Berry says.
  • She had had multiple preceptors in orientation and several recommended that she stay in orientation longer because she was not ready to solo. The unit manager disregarded that advice because she was short staffed. The hospital decided to limit the number of preceptors and improve communication among them. Policy also now requires that the preceptors and unit manager all agree the new nurse is ready to come off of orientation.
  • The nurse took three attempts to pass the orientation medication test. The hospital subsequently changed its policy so that only two attempts were allowed and then the nurse had to go back for orientation focused on medications or process.
  • The organization did not have a medication order template. Pharmacy had not had an opportunity to clarify the orders.
  • The automated drug dispensing system allowed 20 mg of morphine sulfate to be removed, but a more modern version of the system would not. An upgrade of the system had been denied in the previous two budget cycles.
  • Senior leadership at the hospital wanted notification as early as possible. Risk managers naturally try to gather information before alerting senior leaders, but it is better to go ahead and notify them even if that means having to say, "I don’t know yet" when they start asking questions.
  • The hospitalist blamed the nurse for killing the patient when the family members backed him into a corner and he couldn’t think of anything else to say.

For that reason, Berry says it is a good to always have another representative with the primary discloser so that when that happens, the second person can speak up and redirect the conversation.

"You need the other person to break in and give the primary discloser a chance to gather himself, regroup, and get the message back on target," she says. "That was an important lesson for us."