This text case demonstrates how a combination of system failures and issues in provider factors can lead to a patient safety incident (or accident in Québec). The facilitation questions and suggestions to faculty focus on helping learners to consider the importance of multiple layers of safety nets to mitigate the impact of system issues on patient safety, as well as the importance of a climate of just culture to promote an institution's ability to learn from a harmful incident (accident in Québec).
It is 04:30 on the Tuesday after Labour Day. An emergency physician is working his third consecutive 12-hour night shift at a busy and understaffed community hospital. Due to family commitments, the physician has slept for only 3 hours prior to this shift.
The physician has recently returned from a 3-month sabbatical. While he was away, the funding envelope for the emergency physicians was reduced, resulting in a decrease in the evening double coverage by 8 hours. An electronic bed board management system and a new sepsis protocol have been introduced, but the physician has not yet received an orientation on either of these initiatives.
Three of the emergency nurses have called in sick. They have been replaced by nurses from a temporary staffing agency, none of whom have had any emergency department experience.
At 04:40, an ambulance arrives with a patient from a long-term care facility. The patient has a history of severe dementia, hypertension, type 2 diabetes, COPD, and bradycardia treated with a pacemaker. The nursing staff at the long-term care facility reports that the patient has been having increased confusion, shortness of breath, and fever. The following vital signs were obtained by the nursing staff at the long-term facility, prior to ambulance transfer, and communicated to the ambulance personnel: P 72, BP 105/70, RR 24, T 37.6, SpO2 91% on room air.
As no beds are available in the emergency department, the patient is placed in a hallway adjacent to the observation area. One of the replacement nurses takes the history and vital signs from the ambulance personnel. No new vital signs are recorded.
The emergency physician sees the patient at 05:20 and is concerned that the patient might be septic. Orders are written for routine bloodwork, lactate, urine and blood cultures, a fluid bolus, a first dose of broad-spectrum antibiotics and a chest X-ray. The nurse assigned to the patient goes on break at 06:00. The covering nurse repeats the patient's vital signs and records a temperature of 39.8, BP 85/60, and a pulse of 72. These are recorded in the chart but are not verbally reported to the other nurse when she returns from her break.
A physician shift change occurs at 07:30. Patients are handed over by reviewing the electronic bed board. Although the patient is registered in the system, he is still assigned to the waiting room, which is not a treatment area that is reviewed during the handover. Consequently, the patient is overlooked and no formal transfer of care occurs.
A nursing handover takes place at 08:00, and only the admitting vital signs are provided to the incoming nurse. At 09:00 the patient is moribund with a systolic blood pressure of 60 and oxygen saturation in the low seventies. Despite attempts at fluid resuscitation and antibiotics, the patient dies of septic shock several hours later.
This case is reviewed at the hospital morbidity and mortality (M & M) rounds the following month.
- Discuss some of the system issues that contributed to this outcome.
- Can you identify some safeguards and/or system improvements that may have helped to decrease the risk of this patient safety incident (accident in Québec)?
- What culture elements do you think are needed to facilitate an investigation into patient safety incidents (accidents in Québec)?
- What are some processes that could be put in place to help the healthcare workers involved in this incident (accident in Québec) process the emotions they are experiencing?
Suggestions to faculty
This text case can also be used to consider the CMPA Good practices, "Physician-patient: Disclosure of patient safety incidents" with the patient's family. Have one learner play the role of the physician, one the role of the nurse, and one the role of the family member.