The knee bone's connected to the thigh bone, the thigh bone's connected to the hip bone......or at least you hope it is

'Exactly what kind of a force Professor Röntgen has discovered he does not know. As will be seen below, he declines to call it a new kind of light, or a new form of electricity. He has given it the name of the X rays. Others speak of it as the Röntgen rays' 
'The New Marvel in Photography'

Almost all ED docs have missed a fracture.

Nope, all ED docs have missed a fracture. Doesn't mean they should all be clasped in irons and thrown in the hold. It does mean though that X-rays are always an area of risk, error.... and learning.

As it was, not that long ago

The author has fond memories of hard films being stuck to windows when all departmental viewing boxes have failed or feeling at risk of epilepsy as fluorescent tubes mercilessly flicker whilst you look for subtle signs of osteomyelitis (aren't all signs of osteomyelitis subtle) Osteomyeltis and Imaging.

 So you would have thought that digital imaging was a great step forward.

 Well of course it is, but errors still occur, sometimes because of the nature of digital media......and sometimes because you can never under estimate the ability for a human to muppet something up.

Here are three X-ray related cases. All real films. all real patients. all with real harm..... But also all with learning

 All of the Films, All of the Time 

 A lady in her 50's, 'AB' presented with a several month history of non traumatic right hip and thigh pain, with extensive swelling and bruising of the thigh.
She was having great difficulty walking. The ED doctor sent AB for X-rays and then handed her over to another ED junior, leaving a clear plan in the notes. ' If X-rays abnormal- admit. If normal- home' 
The second doctor reviewed the films......

............declared them normal and sent her home with GP follow up.

In the following days she had a torrid time. She became entirely immobile, bed bound and unable to get to the toilet in time. Her GP, reassured by the recent ED visit prescribed her morphine and arranged urgent Musculoskeletal out patient review.
Hey, the X-rays are normal right? What could go wrong?

After ten days an Intermediate Care Team visit lead to an ambulance being called. On arrival at the ED for the second time her right leg was now externally rotated and short. An ED Reg saw her and sent her for repeat films which unsurprisingly showed a proximal femur fracture.

When the Reg reviewed AB's previous films taken 10 days before, he saw that the pelvic film had been red dotted by the radiographers and clearly showed a hip abnormality. This turned out to be a pathological fracture related to a disseminated malignancy. Bony Mets on X-rays

erosion of the cortex of the lesser torchanter

Sadly AB died 4 months later.

Whilst the eventual outcome for AB would not have been changed by the diagnosis being made ten days earlier the letter of complaint makes it clear how terrible those extra days at home were

 the pain was intolerable…she could do nothing but sit for hours on her landing until her neighbour could attend and carry her back to the bedroom. Her bed had to be changed due to incontinence, her leg had rotated and this was very frightening

 The quote is included not to sensationalise, but to remind us of how 'simple' decisions we make day to day can have hugely significant effects on lives

Learning Bite
The doctor who reviewed AB’s initial films missed the abnormality even though it was red dotted because they ONLY looked at the shaft of femur and knee films, which are indeed normal. They did not look at the pelvis films.

 PACS is a very useful tool BUT it can make it easy to miss all the films, or look at the wrong date or even the wrong patient’s images.

 So Triple Check- Is it the right patient? Is it the right date? Have I seen all the films?…..and finally if the films don’t seem to make sense for the patient in front of you. Double check the films and double check the patient.

Too obvious? 

LM a 20 something year old man, attended four days after an accident sustained on holiday. He had dived into a swimming pool and struck his head on the bottom. He had immediate neck and arm pain, and felt his arms were weak. He managed to climb out the pool after a few minutes.

A local doctor advised him that he had a muscular sprain. On return home he initially attended a MIU, who immobilised him and sent him to the local ED. On arrival he was log rolled off the board by a senior doctor who noted normal neurology and sent him for an x-ray of his neck.

On his return he was fully assessed by a different doctor who clearly documents the history and some possible right upper limb weakness. The doctor reviewed his x-rays including a swimmer’s view before making a diagnosis of neck sprain and discharging him without further senior review.

Six days later a radiologist contacted the ED to advise that LM had a fracture of C6 and the swimmer’s view did not show the C7-T1 junction.

 Unfortunately the ED had no patient contact phone number so attempts to recall him immediately proved futile. A letter was sent out to LM’s home address, but he did not receive that for a further four days.

Ten days after his first ED visit LM re-attended and was sent for CT, then MRI. This showed further minor fractures of C7 & T1 with evidence of ligamentous instability. He was admitted and underwent surgical repair the following day.



Learning Bite

LM had ‘the’ classic history for a forced flexion neck fracture. This should always make you raise your index of suspicion.  i.e ‘It’s such a good story that I am expecting a fracture but can’t see one- I had better talk to a senior.’

How do you know your contact details are correct in the event f recall?

How do you ensure radiology can feedback in real time?

Too likely? 

A man in his 70's fell down some stairs and hurt his back. He had suffered back pain for many years so was used to being sore but he thought this was worse than normal.

An ambulance was called and he ended up being seen in an ED. He was deemed to have no significant injury and discharged back home without imaging but with painkillers.

 Two weeks later he was still struggling. His analgesia requirement had increased and he was not able to mobilise as well as before the fall.

Another ambulance was called and he ended up in a different ED. They decided that X-rays of his lumbar spine were indicated. Theses were reviewed and declared as showing no fracture. So...... he was sent home with a further change in his analgesia.

Ten days later the X-Ray department at hospital two contacted the ED and said that they thought there might be a fracture on the patients lumbar films but weren't sure. The ED phoned the patient who was still struggling away and sent out an ambulance.

On review he was sore throughout his spine but most notably in his lumbar region where he said he could feel some grinding, clicking and movement..... Movement ? So?...

Well the 'killer' fact missing from this review is that thus chap had a well established history of Ankylosing Spondylitis and had been fixed in the classical 'question mark' position for the past 15 years at least. Ankylosing Spondylitis

 His lumbar films do show a fracture.....

What fracture?

But the patients altered anatomy is so unusual that you would be forgiven for thinking 'Meh! That's a soft tissue shadow'......and that's kind of the point

there it is - right through L4 and all the posterior calcification

Question Mark Spine

The whole spine CT showed just how abnormal his whole spine is, and also clearly showed the fracture

 Learning Bite 

'Ank Spond' patients fall over.
 When they do they usually break something..... Assume, until you can be SURE that they don't, that they have a spinal fracture

Plain films in this group are abnormal before they have a fracture.
Their plains films are notoriously hard to get right. Consider CT as the investigation of choice

Finally, if an AS patient does have a fracture, then the long sections of fused vertebrae either side of the fracture mean that there is lot of leverage at the fracture site and neurological deficit is common.

Final Comment

When we send people home they trust what we say (amazing, but true)

This can mean that folk stay at home in the face of quite dire symptoms

It's really important to give them advice about when, where and how to re-access care.... and then document these 'triggers to return'

Irrelevant Nonsense

One for your kids

'Simple' Drug Errors- Tales of False Reassurance

'drink me'

Most senior health care professionals have a few drugs , their indications, interactions and doses so well embedded In their brains that they do not need to look them up.... But most of them have to turn to the trusted British National Formulary every now and again. More junior staff probably use the BNF more than senior docs, but as the author can attest 'tempus fugit' and having access to a BNF in hard or e-copy is an essential pre-requisite of safe EM.

But can using a BNF actually cause a drug error?...... course it can't. 
Can it?

Sadly the ability for the typical human to find the way to err (in medical parlance, 'cock something up') should never be under estimated, even when trying to do the right thing.





1-Route Cause?

A lady in her 40s presented with chest pain. A junior doctor saw her, made a full assessment and thought that her pain was most likely to be  gastro-oesphogeal in origin. He wanted to provide her with analgesia, but felt that her pain was not severe enough to warrant intra-venous morphine. He did not wish to provide her with a non-steroidal based drug, as he felt this might worsen her possible dyspepsia. 
She had already taken paracetamol at home within six hours. 
So he did the right thing, he asked advice.
'Do we have something not as strong as morphine but better than paracetamol?'
A senior nurse suggested codeine.
The junior doc was not familiar with codeine doses.
So he did the right thing, he went and looked it up in the BNF.
The patient had vomited once so the doctor thought he should use a parenteral route

Unfortunately he misread the BNF entry and did not note that codeine can only be given orally or into a muscle.
He prescribed the right dose.............but into a vein not a muscle.

Once prescribed he did the right thing.
He asked a nurse to give the patient the drug.
The junior nurse had heard the conversation between the doctor and the senior nurse and had also seen the junior doctor reading the BNF. She was also unfamiliar with codeine, but she had just seen the doc check the drug in the BNF, it was busy (isn't it always?)
The drug was delivered IV

The patient had an immediate 'rush' and felt 'awful', but this settled within a few minutes. This drug error led to 'no further harm', but that was serendipity not design.

Comments
Despite lots of really good, thoughtful care, a drug error still occurred. Completely well intentioned actions with the best motives resulted in harm. Good God man, they even read the BNF first.....

Someone must be to blame!

When the senior doctors were informed of this error, almost all of them immediately said
'Why do we have codeine solution in the ED I never use it?'
'IM analgesia, in an ED. Why?' 
(yes there are exceptions)

An immediate action was to remove all codeine solution vials form the ED within 24 hours.


2-Not all syringes are equal

A renal patient in his 30's came into the ED with symptoms of weakness, lethargy, low blood pressure and slow heart rate. 
He said, 'I've had exactly this before when my potassium levels have risen too high' 
The junior doctor who saw him established that hyperkalaemia was the indeed the correct diagnosis using a venous blood gas. The doctor then did the right thing, they immediately discussed the patient with a senior saying that they were moving the patient to the resuscitation room for standard hyperkalaemia treatment under cardiac monitoring.

Within 10 minutes the correct diagnosis & treatment plan were established with onward referral to the ward already made. All going well so far!

The junior doctor prescribed an insulin/dextrose infusion in line with the trust guidelines which they looked up on the hospital pharmacy website (they did the right thing). The doctor directed that 10 units of fast acting insulin should be used in the infusion, and did the right thing, by prescribing it all on an IV fluid chart with correct doses volumes and rates. They even wrote out 'ten international units of soluble insulin' in long hand.(see MPS link at end)

Resus room nursing staff drew up the correct volume of 100 units per ml soluble insulin, but did so in a standard 1ml syringe, not an insulin syringe. That volume is, 0.1ml. The doctor caring for the patient thought this volume looked wrong, so did the right thing.......... and checked.

Having searched and read the BNF the doctor recalculated the dose and decided that 1ml was the correct volume to give to achieve 10 units. 

Resus was busy (isn't it always?), so the nursing staff had been called away to a sick patient in another bay. The doctor was concerned about their patient so just wanted to 'crack on' with treating him...so despite never having made up an insulin infusion before drew up 1ml of actrapid (100 units) and used that to make the infusion and then filled in the additive label writing that it contained 'ten units of insulin'

The infusion was checked and signed by two nurses, one from the resus room

and one from another area of the ED (because, as you may remember, resus was busy), before being connected and given to the patient. The resus nurse knew that 1ml of insulin had been used not 0.1ml, but had seen the doctor check the BNF .............so assumed that her first calculation was wrong and that he was receiving ten units

The patient (unsurprisingly) almost immediately began to exhibit symptoms of hypoglycaemia and the error was equally rapidly noticed and corrected. An immediate explanation  and apology was  given to the patient and he was told that a formal review of the incident would be undertaken.

Fortunately the patient came to no harm except more frequent BM measurement, which was uncomfortable for the patient, but did him no long term harm, but again this was serendipitous.


Learning Bites

Insulin syringes are specifically designed to avoid dose errors by being graduated in units not millilitres.  Only use insulin syringes when drawing up insulin.(MPS on Insulin)  & Yorkshire Water Torture

All drug calculations must be checked by two trained health care professionals, as should the doses and volumes put into infusions prior to delivery to the patient

If you haven’t done something before, Resus is unlikely to be the place to start doing it

If you’re not sure about something ask.

If you think someone else has got something wrong it’s OK to ask

A culture of 'its ok to ask' is not a sign of weakness nor 'thickness' but of good safety processes


Commentary
In a system reliant on humans it is impossible to prevent all errors. The best you can do is try to maximise the barriers to error. Which is why I really object to 'aspiring to zero harm'. If you aspire  to the impossible, then you will always fall short and in the process mislead the patients and staff. 

From the patients perspective 'if harm is entirely avoidable then I should not come to harm. If I have, someone is to blame'

From the HCPs perspective 'if i make a mistake, I will be blamed. I could be disciplined. I could lose my job. I could lose my house. I'm not telling any about this and hoping they don't find out'

So who is to blame?

Well actually no individual is solely to blame. As with most healthcare incidents there was an alignment of system weaknesses that let both patient and the staff involved down. This is frequently described as the Swiss Cheese model.

It is rare that one person does something so enitrely inexpilcable that blame can be laid at their door alone. And anyway blame is such an emotive word. Once an incident has occured you cant undo it, but what you can do is reduce the chances of it re-occuring. 

We, the NHS, and EM more widley need to share learning and promote safety by embracing openness and honesty and avoiding blame.

Lets learn not blame

Lets share not hide


Random Link

bonus points available to anyone who knows what this chaps link to the above is

Leonard Thompson

Under Pressure

So here's a starter. 

Doctors and nurses by nature are well intentioned when it comes to patient care, especially in emergency situations. Unfortunately  good intentions can sometimes lead to problems

Under Pressure

A patient arrived in the Resus Room following a Cardiac Arrest having been ‘shocked and tubed’ by paramedics. As part of the Critical Care work up the patient had and Arterial Line inserted.(How to put in an A Line) 

The patient’s blood pressure was low, so fluid was requested to be placed in a pressure bag and infused more rapidly.  A member of nursing staff heard the order and provided a pressure bag to the team.

The patient’s Arterial BP did not improve with these fluids so a Noradrenaline (NA) infusion was started. However the patient's blood pressure still failed to respond. It was then noticed that the pressure bag that had been used to provide fluid directly to the patient's intra venous line had been taken from the Arterial line transducer set. As a result that the A-Line BP had been incorrectly reading low. When the A-line set was corrected and re-calibrated the patient’s BP was 170 systolic. 

A few minutes later the patient rapidly developed pulmonary oedema and required IV diuretics. Once the patient had stabilised enough to allow transfer they went to the Cath Labs for coronary angiography. 

Fortunately the patient went onto make an excellent recovery and is back at full time work with excellent ventricular function.

It is impossible to know how much the wrongly calibrated A-Line readings contributed to the patient’s subsequent course, but it is unlikely to have helped.  

Learning Bite

The nurse who took the pressure bag off the A-line transducer did not know that it was an integral part of the kit. Despite having the best intentions of trying to help, the nurse’s actions had the reverse effect. 
This was because they were not fully trained in IV administration or Resus Room equipment.  

Healthcare staff should not carry out actions or use equipment unless they are trained to do so. More training is being introduced as a result of this event

Additionally new ‘A-line Badges’ are hung on A Line pressure bags to make it clear that they are part of the system. These are stored with each A Line kit in resus.

Comment
This is a fairly straightforward case with a happy ending for the patient. 

That sadly is not always the case when staff try to do their best. The learning bites were  my thoughts about outcomes that reduce the risk of recurrence, but I would be delighted to hear of others. please add your own comments

Errors should not lead to blame but to learning. 

That's why this blog is here- shared learning

In the next few blogs I hope to highlight some of why Don Berwick matters, and why we need a Clinical Governance revolution and share some more EM errors

What's all this about then?

.

Hello,
Thanks for reading this

I am a UK Consultant in Emergency Medicine. I work in the NHS, with all it's great bits, less great bits and frustrations. In my practice I see lots of amazing care, but I also sometime see or hear about things that don't go so well.

Healthcare is by its nature a risky business with EM at the further extremes of even that. Making life changing decisions, in minutes with zero previous patient information in a high intensity environment 24/7 is bound to result in the occasional error. No one expects doctors not to make mistakes, although sometimes reading the press you wonder, but what is also equally true is making the same mistake twice is stupid. Learning from errors is vital. In fact most experienced doctors would say that they have learned most from errors they have made or seen. 

However .........

Most UK EM teams are made up of a variety of staff in which most of the doctors rotate anywhere from yearly to every 4 months. So how do you let this lot of doctors know about the errors of the previous lot?
How do we stop an error being made in 2013 that was previously made in 2009?
How do you try to inform all your staff in a timely way...especially when there's a couple of hundred of them?
Can you put a wiser head on younger shoulders?
How do we truly learn from the errors of the past?

Can we move to an NHS based on Don Berwick? Berwick Report

• ●  Place the quality and safety of patient care above all other aims for the NHS. (This, by the way, is your safest and best route to lower cost.) 
  

This blog will try to share learning, improve safety and lower risk by bringing cases based on real ones into a more open forum. None of it will be rocket science, although occasionally it will be brain surgery.

It's intended that by sharing errors, we can share learning. And by sharing learning we can do less harm

“Any man can make mistakes, but only an idiot persists in his error”

Cicero

Who?