reviews the name and location of my procedure
marks my body on the correct spot with his or her initials
I will speak up if anything is incorrect, doesn’t seem right, or if any of the three steps are skipped.
Table 4.4.
WHAT YOU CAN SAY
Sticky Message:
Catching Minor Mix-Ups Prevents Major Screw-Ups
When Scheduling a Surgery or an Invasive Procedure
Patient Request
Professional Response
“Since we don’t want anything to go wrong, do you use the Universal Protocol to perform time-outs with patients?”
“Yes, we use the Universal Protocol. Thank you for asking. I’m glad you know about it.
It is important to participate in the time-outs, so you must learn the name of your procedure and know exactly where it will be performed on your body. We will write this out for you, but let’s go over that information now.
The name of your procedure is ___. It will be performed here ___.
To make sure I’ve been clear, would you repeat that back to me?”
Before the Body Is Marked or Before the Patient Is Sedated
Patient Request
Professional Response
“I’m glad you’re marking my knee, but let’s make sure I’m scheduled for the correct procedure.”
“Absolutely! I almost marked your leg without verifying your ID and the name of your procedure. Let’s start again.”
“Wait, before you sedate me, the surgeon has not marked my body with her initials.”
“Thank you for stopping me. I thought that had been done. I’ll be back after the surgeon has reviewed the procedure with you and marked your body.”
If you are interested in more detail, ask your healthcare providers for a copy of the Universal Protocol or search it online to (a) reinforce your familiarity with the checklist process and (b) support their efforts to consistently use the Universal Protocol.
Chapter 5
Deadly Doses and Dangerous Drugs
Avoid Medication Errors and the Overuse of Opiates
Josie King
Eighteen-month-old Josie King was admitted to the hospital for second-degree burns. Over the course of about two weeks, Josie was treated with opiates to control her pain. When Josie’s mother, Sorrel, arrived at the hospital early one morning, she found Josie to be unresponsive and called for help. The staff immediately gave Josie a dose of naloxone—a rescue medication that quickly and temporarily reverses the effect of opioids. The naloxone worked briefly, but a second dose was necessary. Both times Josie received the rescue medication, she perked up and wanted something to drink. Later that morning, Sorrel told Josie’s surgeon, with whom she had developed a good relationship, what happened. The surgeon agreed to discontinue the painkillers and issued a verbal order to do so. A few hours later, while Sorrel was rubbing ointment on Josie’s feet, a gruff nurse who was new to Josie and Sorrel arrived with a syringe of the pain medication in hand. Sorrel questioned the nurse, but the nurse rebuffed her concerns. The nurse injected the opiate in Josie and almost immediately Josie’s eyes rolled back in her head. She quickly became unresponsive. Sorrel screamed for help, but it was too late. Josie went into cardiac arrest and experienced oxygen deprivation that left her brain dead. As a result, two days before she was to be discharged from the hospital, Josie died.1
Nothing About Me without Me
Even though a great deal has been written about this event, including Josie’s Story, a memoir by Sorrel King, it still has great currency for bringing to light issues related to the safe use of drugs inside (and outside) hospitals and other healthcare settings.2 The cascade of errors that led to Josie’s death is what makes it such an illustrative, though heartbreaking, patient safety story. How the hospital responded to Josie’s death is as inspiring as the story is tragic.
During the course of being treated for second-degree burns, doctors had placed a central line catheter in Josie. The central line was used to make it easier to administer essential fluids and medications. Along the way, the line became infected. Because Josie’s doctors planned to discharge her within two days, they decided to remove the central line and administer medications orally. As a side effect to the oral antibiotics, Josie began having diarrhea and vomiting. Without a central line in place to deliver fluids, Josie became dehydrated. When a patient becomes dehydrated, his or her condition can deteriorate rapidly, which, in turn, can cause the body to go into a dangerous state of septic shock. Sometimes behavioral signs of septic shock are apparent before clinical tests and other metrics make the problem obvious. Indeed, Josie’s fluid input and output metrics looked okay, but they belied what Josie’s mother saw. As you will learn, Sorrel’s observations and resultant concern were mostly ignored. Consider this excerpt from Sorrel’s book:
I asked her [the nurse] what she was doing and told her that Dr. Paidas had given orders for Josie not to receive more methadone.
“Don’t give it to her,” I said as she neared Josie’s bed.
“The orders have been changed,” she responded.
Something didn’t seem right. Why were the orders changed? Should I knock the drug out of her hands and scream for help? Was I missing something? Stop, slow down, I told myself. I am at Johns Hopkins, the best hospital in the country. These doctors and nurses are the smartest. They know more than I do. They must have changed the orders for a reason, a good reason. They know what they are doing. I moved aside and stood there as Brenda [the nurse] squirted the drug into Josie’s mouth. I continued rubbing ointment on her feet.
“Look, a crocodile tear,” Amy [another nurse who was familiar with Josie] said.
I looked and there it was, one single tear sliding down Josie’s cheek. I wiped it away, thinking to myself how strange it was that in the two weeks since Josie and I had been in the hospital this was the very first tear I had seen. I began taking off my gloves and cleaning up, but when I looked back at Josie I stopped dead in my tracks. Her eyes had rolled back in her head. “Josie? Josie!” I shook her. She was not responding. I screamed for help. Amy screamed for help and starting pushing buttons on the monitors.
“Look at her! Look at her! Someone help!” I screamed.
A dozen nurses and doctors raced to her bed with metal tables and trays and equipment. I felt myself being led out of the room and into the hall . . . They put me in a small, windowless room. A chaplain stood quietly in the corner, and I wondered why he was there.3
At first, the hospital told Josie’s parents they suspected Josie had succumbed to a massive infection, but Sorrel thought otherwise. Eventually, the hospital realized that the opioid painkiller (methadone) was central to this event. Josie’s body did not tolerate the last shot of methadone. After the drug was administered, Josie experienced a cardiac arrest that led to oxygen deprivation. Because Josie no longer had a central line, it was difficult to get rescue medications into her quickly. The time without oxygen resulted in brain damage. And Josie, who was on the verge of being discharged after more than two weeks of successful hospital care, died.
The surgeon ordered pain medications stopped because Josie no longer appeared to be in pain and because opioids can cause or intensify dehydration, which had become apparent to Josie’s mother. However, the pain management specialist, an anesthesiologist who saw Josie later that morning, was more concerned about the consequences of abrupt withdrawal from the opioids. By the time the anes
thesiologist saw Josie, the surgeon had left the unit, although one of his surgical residents was still there. The resident disagreed with the anesthesiologist’s concern, so the anesthesiologist pulled rank. Without speaking to the surgeon, she ordered more opioids (although at a lower dose).
What makes this case disturbing is that the anesthesiologist knew Sorrel had her guard up against more pain medication for her infant daughter, yet she chose not to share her thoughts or decision about ordering more painkillers with Sorrel—effectively cutting the patient’s advocate out of the loop. When Sorrel objected to the nurse giving the medication, the nurse dismissed her concerns and disregarded her objection.
The Swiss cheese effect had taken hold. A cascade of errors culminated in failure of the worst kind. The hospital didn’t protect Josie from picking up an infection, a communication breakdown between physicians led to poor management of a powerful painkiller, a failure to communicate prevented a mother from having a say in her child’s care, and a nurse disregarded a mother’s expressed objection to treatment. Oops, oops, oops, oops, boom!
Josie’s story screams for better teamwork to improve communication among all members of the healthcare team. Patients and families should not have to bully their way onto the team. After Josie’s death, many hospitals started completing rounds at the patients’ bedsides, with the express purpose of involving them and their families in the decision-making process. There is ample evidence to demonstrate that this type of communication improves the quality and safety of care.4 Bedside rounding has been shown to add additional and relevant information in nearly half (46 percent) of the rounds.5 Regardless, rounding at the bedside supports the humane and compassionate concept of “nothing about me, without me”—something that has been discussed by patient safety leaders for some time6 and that the National Patient Safety Foundation aspires to enable all patients to express.7 After all, a physician’s propensity to err is great, although often denied, and a patient is often the only person who can provide a critical piece of information that may avert disaster.
A Medicated Society
Modern societies, and the United States in particular, have become reflexive in associating symptoms with drug interventions. At last count, seven out of ten Americans take at least one prescription medication on a daily basis. More than half of all Americans take two types of daily prescriptions, and nearly a quarter takes five or more daily.8 In one year alone (2011), 4.02 billion drug prescriptions were written for US patients. This equates to an average of thirteen prescriptions for every man, woman, and child, with roughly one new prescription every month for every American.9 This massive amount of daily drug use does not include over-the-counter or hospital-administered drugs. Research indicates that over 80 percent of US adults use over-the-counter drugs as a first response to minor ailments with a total of 2.9 billion retail trips annually to purchase over-the-counter medications.10
Perhaps it should be no surprise that dangerous drug combinations represent a leading cause of hospitalization. National data indicate that by 2005, nearly 7 percent of all US hospital admissions were specifically for adverse drug reactions,11 with a rate that is more than one-and-one-half times higher among elderly patients.12 In addition to the medications patients are on when they are admitted to a hospital, additional drugs are almost always added to their regimen after they are admitted. Ensuring that hospital patients receive the right medications, at the right times, in the right doses, and through the right routes can be extremely complex and complicated.
Epic-Level Drug Harm
Like healthcare-associated infections, hospital-induced medication errors have reached epidemic proportions. They alone represent a major public health crisis that appears to be intensifying each year. Fifteen years ago, To Err Is Human estimated that seven thousand US hospital patients were dying annually as a result of medication errors. It is now widely accepted that this figure represents a significant underestimate of the magnitude of the problem, then and now. Besides the historic issue of the underreporting of hospital-based medication errors, the number of medications that patients take before, during, and after they are hospitalized is much greater today than it was in previous decades. With the increased rate of medication use, the risk of medication-related harm and error has increased exponentially.
Looking at data from a single year (2011), 286.2 million drug orders were placed for patients admitted to US emergency departments, and another 329.2 million orders were placed for patients admitted to US hospital outpatient departments, totaling over 615 million drug orders among patients treated at hospitals without being admitted.13 In that same year, millions more drug orders were placed for patients who were admitted to inpatient units.
A major investigation of data during the 2006 to 2008 time frame indicated that more than seventeen billion drug orders were written for hospitalized patients annually.14 Also in a single year (2000), individuals living in nursing homes were found to receive an average of nearly seven routine prescription medications per day and between two and three additional medications on an “as needed basis.”15 And the rate of prescription drug use among nursing home residents has been on the rise ever since.16
It is impossible to come up with a single figure or estimate that would accurately capture the extent of harm that results from current rates of drug ordering, prescribing, and over-the-counter purchasing. That is a black number—a number that is not precisely knowable. Nonetheless, the US Food and Drug Administration has a reporting system that sheds some light on the subject. This system, which is commonly called MedWatch, is the world’s largest database of voluntary, spontaneous reports of adverse drug reactions and drug errors.
An adverse reaction refers to instances of unintended or harmful drug reactions that could not be predicted, such as a first-time allergic reaction. A drug error refers to a preventable mistake that has the potential to cause harm while in the control of a healthcare professional, patient, or consumer. For example, prescribing a drug to which a patient has a known allergy would count as a drug error.
While MedWatch includes all adverse drug events, the voluntary nature of the system assures that its data generates gross underestimates of the full magnitude of adverse drug events, including an underreporting of drug errors.
A few years ago, researchers used MedWatch to conduct an in-depth analysis of adverse drug reactions from 1998 (when the system was first created) through 2005.17 They discovered that both the rate of US prescriptions and adverse drug reactions increased each year. In 2005 (the last year of the study), MedWatch documented 15,107 fatal adverse drug reaction cases and another 89,842 serious adverse drug reaction cases—cases that caused harm but did not result in death. Furthermore, the annual increase in adverse events grew four times faster than the rate of prescriptions, especially among elderly patients.
Frequency and Cost of Drug Errors in Hospitals
To get a handle on the relative frequency of adverse reactions versus drug errors, one study looked at ten common types of unanticipated patient harm and then checked to see how often each harm category was due to an unavoidable complication versus an error. Only one out of the ten categories was more likely to occur as a result of an unavoidable complication—drug-related events. Specifically, error was involved in only 10 percent of drug-related instances of harm. Yet in the other nine categories of patient harm, human error was involved in 35 percent to 91 percent of the cases.18 Even a 10 percent error rate among the high volume of hospital drug orders would amount to tens of millions of medication errors per year, a significant portion of which would result in death or serious harm. In fact, that is precisely what more recent evidence suggests. A 2013 publication that was based on a rigorous analysis of national databases indicated that, as of 2008, over 1.7 billion drug orders were processed in US hospitals with up to 1.7 million drug errors.
To Err Is Human suggested that—based on a conservative assessment—seven thousa
nd medication-related hospitals deaths occurred among US patients each year.19 At the time (1999), this figure was shocking. Today, patient safety experts can only wish that the magnitude of harm were as low as that report originally estimated.
Recently, the Institute of Medicine estimated approximately one medication error occurs per day for every US hospital patient.20 Some researchers have documented that at least one million serious hospital medication errors occur each year;21 others have estimated that approximately 20 percent of hospital medication errors could be life threatening.22 Astounding as such figures are, recent research by the Office of the Inspector General indicates that the rate of preventable drug harm to Medicare beneficiaries in nursing homes exceeds that of hospitals.23
No matter how you look at it, the rate of medication error and associated harm that occur in hospitals, nursing homes, and the community is beyond any rational level of comfort. And this is an expensive problem. As of ten years ago, on average, medication errors added $2,000 to the cost of a hospitalization, which amounted to over $7.5 billion in annual US hospital charges.24 In today’s dollars that would amount to over $11 billion annually.
Why So Many Errors?
How could there not be so many medication errors? Within a hospital environment, it is common for one physician to order a medication that one or multiple nurses will administer, while other physicians and nurses monitor its effects and alter the patient’s subsequent drug regimen. Along the way, the prescribing physician must communicate the treatment plan with whomever might administer the medication. Once a drug is ordered, it must be obtained from the pharmacy, checked against the patient record for allergies or other adverse indications of its use, and administered to the right patient, in the right dose, via the right route, and at the right time. At every step, someone must determine, through observation or inquiry, whether the medication is working as intended and without ill effect. Every step of this process must be documented, and every step is a source of potential error.
Your Patient Safety Survival Guide Page 11