See One, Do One, Take it Home! Root Cause Analysis 2 Simulations

Transcription

1 Role Description: Emergency Department Physician s Assistant You are the Physician s Assistant (ED PA) who evaluates the patient in the Emergency Department. You are the first provider to interview the patient. While taking the initial history, the patient notes that he might be allergic to morphine but states you have to check with my wife, she knows my entire medical history. You write this in your H+P and wait for the patient s wife, who went to the hospital cafeteria to get coffee. Before the patient s wife returns an inpatient bed becomes available. You are under pressure to reduce ED length of stay and move all admitted patients to inpatient beds as soon as possible. You feel especially pressured because the ED is overcrowded today and a few staff members called out sick for the July 4 th holiday. Knowing that the medicine resident will do a full H+P with the family and the patient in the next half hour, you page the medicine resident for pass-off and send the patient to the inpatient bed before his wife returns to confirm his allergy history. During pass-off, you use the I- PASS mnemonic (which does not have a structured field for allergies) and forget to mention this detail. **Fictitious case for teaching purposes only** 1

2 Role Description: Medicine Resident #1 You are the Medicine resident who admitted the patient (Medicine Resident #1). When admitting the patient to the floor, you note that in the ED note there is a mention of a possible morphine allergy. You weren t aware of this during pass off. You ask the patient's wife and indeed, she notes that the patient got a rash last time he had Morphine but tolerates Dilaudid well. You did your EMR training and was even a superuser (local EMR expert), but think the electronic system has too many clicks. When interviewed you admit that although you know you are supposed to put allergies in the coded allergy field, you didn t since you were at the end of your shift, eager to get home and figured it just didn t matter that much since you wrote it in the H+P. Anyone that is caring for the patient should read the H+P. At 7am, you rotated off the service and handed the case off to your counterpart (Medicine Resident #2) without mentioning the allergy. **Fictitious case for teaching purposes only** 2

3 Role Description: Medicine Resident #2 You are the Medicine resident who picks up the patient after Medicine Resident #1 rotates off service. You come on service and are now caring for the patient. You get a very brief pass-off from the resident that covered the patient overnight. The pass off does not include the patient s allergy history. During morning rounds you discuss the patient's increasing complaints of pain. You exhaust non-opioid analgesic options and then write an order for a Morphine PCA. You also write a consult request for the pain management service to see the patient. **Fictitious case for teaching purposes only** 3

4 Role Description: Staff Nurse You are the staff nurse who was assigned to care for the patient on the evening shift. You learn during report that medication scanning has been down for the past 24 hours. You enter the room after getting report and find that the patient is in excruciating pain. You page the medicine resident to tell him/her that the non-opioid medications previously administered have not improved the patient s pain. After the resident orders a Morphine PCA you note that the Omnicell is empty. You page the pharmacist who later delivers up a bag of morphine. You find the patient writhing in pain. You hang the morphine quickly and administer a 2mg bolus of what you think is a 1mg/ml concentration. You leave the room to administer an antibiotic to another patient you are caring for that night. When you return to the patient s room approximately 15 minutes later you find the patient is somnolent, apneic and difficult to arouse. You check the bag and confirm that it contains Morphine but discover that the pharmacy sent a much higher concentration (10 fold increase) than what was ordered. You check the patient s vital signs and find that the BP is now 80/55 HR 75 and O 2 sat is 88. You are concerned and call a rapid response. You note that this mistake would have been caught if the medication scanning devices were working. You file a safety report once the patient was sent to the ICU. **Fictitious case for teaching purposes only** 4

5 Role Description: Pharmacist You are the pharmacist who approved and prepared the morphine order. You review the allergy section of the patient s electronic chart and find that no known drug allergies were entered. You approve the order for morphine as written. You immediately get a call from the floor nurse stating that the Omnicell is out of stock and that Morphine 1mg/ml needed to be delivered from the pharmacy. Four different concentrations of Morphine were available on the hospital s formulary and stored in adjacent bins in the pharmacy. When you went to select the appropriate concentration of Morphine you are interrupted by a phone call from a hospitalist who wants to discuss antibiotic dosing for a different patient. After completing the call, you follow standard procedures, but mistakenly select a higher concentration from an incorrect bin and then deliver it to the patient s inpatient unit. **Fictitious case for teaching purposes only** 5