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
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.
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
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
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
