Tuesday, 26 January 2016

Drugs- Root Cause Analysis, Learning from Other Specilaties & NatSSIPs

Drugs- Don't Stop Til You get Enough?

EM physicians deliver drugs many times a day.......... but most have a common lexicon of drugs they use, if not every day, certainly every week. These familiar drugs are just that, familiar.  
We know their indications, contraindications, mixing agents, routes and rates of delivery.  
Outside that comfortable ball park things can be more challenging. That's fine, we all have a huge variety of resources  to turn to. Here in the UK the bible is the British National Formulary which tells you everything you ever wanted to know (and probably quite a lot you didn't) about any medicine available in the UK.

Medicines Complete is a great resource which may even be free in your NHS hospital.. and that really does have more information than even the most zealous pharmacist in the country could ever want.
But what happens in an 'emergency'. The patient's pulse may be up a bit. They may be looking a little pale and sweaty. Your pulse is up a bit. You may be looking a little pale and sweaty. But hold on- you do know whats going on and you do know what to do. This patient needs drug X... and they need it now.
Here's a couple of cases where a 'stop moment' might have helped (see the end of this article)

Route Cause Analysis


A 60 something year old lady was being treated for possible encephalitis. Shortly after administration of cefotaxime and whilst the aciclovir was still running she complained of shortness of breath and lip swelling.  A diagnosis of anaphylaxis was made and a verbal instruction for 1:1,000 adrenaline, 500 mcg was made by the treating doctor. No route was specified. The drug was drawn up and the aciclovir disconnected. The adrenaline was then given, but in error the intravenous route was used.
The patient had a brief period of hypertension and some short runs of VT over the next few minutes before settling apparently without further issue. She did not suffer any chest pain but did raise a troponin.

Good Care

An immediate apology was given, and an investigation launched including a duty of candour letter being sent.

What Went Wrong

The staff member who gave the IV dose in error knows perfectly well that adrenaline should be given IM in anaphylaxis. However she was distracted by disconnecting the IV acyclovir which she did immediately prior to picking up the adrenaline syringe.
The drug prescription was not written but given as a verbal instruction, this meant a route check was not made against the script.
There was also an atmosphere of anxiety at the time due to the perceived urgency of the situation

Learning Bites

This is a classic ‘human errors’ mistake.  The staff were anxious, a little rushed, a little bit distracted and were doing something they rarely do- a potent ‘cock-up’cocktail.
There are very few occasions that a drug truly cannot be written up before it is given- allowing a check to occur.
If you are about to deliver a drug or perform a procedure that you do rarely- make yourself pause- ‘right patient, right procedure,right site’-  It’s your own stop moment of safety 

Resuscitation Council UK- Anaphylaxis Guidance


Trivial Trivia- Take your Pick

Adrenaline - the name given to a purified extract of adrenal glands by Jokichi Takamine in 1901 - it’s Latin for ‘above the kidneys’

Epinepherine - the name given to a purified extract of adrenal glands by John Abel in 1897 - it’s Greek for ‘above the kidneys’

What’s in a Name- Check Me?

A man in his 40s became unwell on the ward. He was noted to be increasingly confused with a fast irregular heart rate of about 140. An ECG showed fast Atrial Fibrillation. He had never had documented AF before. He was discussed with the cardiology on call team who recommend use of an intravenous beta blocker, metoprolol. The doctor wrote the prescription up. Two nurses then checked the prescription and drew up the drug together. The syringe was passed to the doctor in an IV tray with the drug vial, for him to provide a third check. He read the drug bottle and administered the drug.
Shortly afterwards the patients’ blood pressure was noted to be very high. The doctor was surprised at this expecting the opposite effect. He rechecked the drug vial and found that he had actually administered a dose of metaraminol. Metaraminol is a drug used to raise blood pressure in patients’ undergoing anaesthesia. It has a brief period of action. Following discussion with ITU, the patient’s blood pressure was left to normalise before metoprolol was given for the AF.

Good Care

As soon as the patient did not respond in the manner the doctor expected he re-checked what he had given. The error was therefore spotted quickly.
A full apology was given a datix completed and staff appropriately supported

Learning Bites

Intravenous medicines must always be independently checked by a second person accredited to administer intravenous medicines
This ‘second check’ must be performed independently. Practitioners should be aware that the process of checking can be adversely influenced by the following factors:
 -Deference to a more senior or experienced colleague
-Presuming the other person has performed the process in a correct, accurate and thorough manner
-Repeating the words and actions with the first person
-Diminished sense of responsibility or complacency in the second checker.
-Lack of time and/or hurrying

In this case all three individuals were senior…it is likely they all falsely reassured each other- 
STOP. CHECK. BE INDEPENDENT

Learning from Other Specialties- 'The Stop Moment'


Anesthetists do all sorts of clever things. But they make mistakes too. This includes wrong site/side regional blocks. This is a Never Event in UK practice. Following 67 reports of wrong side block over 15 months the Safe Anaesthesia Liaison Group developed a 'Stop Before You Block Campaign

What's that got to do with me in my EM practice I hear you cry?
Well- when was the last time you inserted a chest drain- what checks did you do before putting pointy object to skin?
Do you perform fascia-illiaca blocks for NoF anlagesia? (if you don't- you should watch this- St Emlyn's )

The anesthetists recognised several common features in their series of errors, just tell me if any of these sound familiar ;



  • Distraction in the anaesthetic room
  • Social activity in the anaesthetic room
  • Human Factors

  • Add in the usual EM rough and tumble and.....


    NHS England has recognised theses issues are transferable and have produced some useful guidance. This is contained within the REALLY IMPORTANT  National Safety Standards for Invasive Procedures (NatSSIPs)

    However  A 'Stop Moment' need not apply to surgical procedures/blocks alone. 

    It just as easily applies to drug delivery, blood transfusion, prescribing.... especially when you are at your most vulnerable to error- stressed, pressured, tired, glycopaenic or working with the unfamiliar.

    I mean, when would any of that ever happen in an ED?

    So try it- try and introduce a stop moment to your practice- 
    Just before you give a drug. 
    Just before you site a needle . 
    Just before you place a knife to skin.

    STOP- Right Patient? Right Procedure? Right Site? Right Way



    Tuesday, 15 September 2015

    The Curse of the Red Dot


    Name That Bone?
    Radiology images can be really tricky to correctly interpret, this can especially be so in the typical environment of a frantic ED......  which quite frankly is as far removed from the quiet, dark, undisturbed setting as you can get. As a result errors around x-rays are not uncommon. 

    Here's a quote from the Royal College of Radiologists that makes this very point;

    Error is inherent in radiology. The available evidence suggests an error rate in unselected radiology practice of between three and five percent. For certain types of specialist examination, where review by sub-specialists has occurred, the quoted error rate exceeds 30%. About 36 million radiological examinations take place in the NHS in England each year, the great majority of which receive a radiologist’s report. A conservative estimate therefore would suggest that close to one million radiological errors occur each year in the NHS. This equates to approximately 4500 a year in an average sized radiology department ie 90 a week. Near misses are even more common


    Everyone who works in healthcare knows this. 
    Everyone tries hard to reduce this. 
    One of the simple measures most hospitals use is the so called 'red dot' system...........

    Situation -The Curse of the Red Dot

    Background

    A lady in her 60's with very poor mobility secondary to a stroke attended the ED with a history of falling during the night whilst visiting the toilet. She was struggling to mobilise at all, with pain in the left knee. She was seen in the ED and sent for X-ray. On her return the images were reviewed and checked with a senior doctor. The images were deemed to be normal and the patient was sent home with a diagnosis of a soft tissue injury.

    Radiology contacted the ED two days later to notify us of a missed fracture. On review of the films there was a  clear missed tibial plateau fracture and it was noted that the original image had been ‘red dotted’ by the radiographers

    The patient was recalled and subsequent films showed further displacement of the fracture. The patient has been admitted for operative repair.

     1st presentation- Red dotted.. but looks ? normal...
    ......aha !



    Assessment

    Good care-  a junior doctor sought advice from a senior doctor

    In the ‘old days’ of hard copy films, appropriately trained radiographers would place a red dot sticker on films they thought were abnormal. This was a safety feature to reduce the chances of anomalies being missed. Digital images obviously cannot have stickers placed on them, so radiographers now write ‘red dot’ on the image.

    Just because a radiographer red dots a film does not mean it is definitely abnormal, however it should raise your suspicion and make you look ‘extra hard’

    This lady had several images of her knee taken, whilst all were red dotted the fracture was much more clearly visible on some than others.


    Recommendation

    If you see a ‘red dot’ image  double check and triple check the image AND the patient

    If you still cannot see what the radiographer seems to be concerned about,  go and ask them what they think they are seeing, they might be wrong……………..but they might be right

    Make sure you look at all the images taken. Only one may show the abnormality.

    http://radiopaedia.org/articles/tibial-plateau-fracture

    http://emedicine.medscape.com/article/1249872-overview

    http://www.orthobullets.com/trauma/1044/tibial-plateau-fractures


    Unnecessary Additional Information
    The image of the radiologist reporting is a tad misleading- its a Sauropod fossil vertebra

    Thursday, 15 January 2015

    'There ain't no party like an SBAR party'

    Case Based Learning - 'The single biggest problem in communication is the illusion that is has taken place

    George Bernard Shaw

    In an attempt to keep the shared learning coming, I am going to try something new in this post.  Rather than pull a series of cases together and combine the learning I am going to share some of the 'SBAR Incident Alerts' I produce for my ED and hospital. Again theses are ALL real incidents. The errors are genuine, and I suspect will be recognisable to all experienced EM clinicians.

    The SBAR (Situation, Background, Assessment, Recommendation ) format is one that will also  be familiar to many. It was originally derived from military use and is a really useful tool to aide clear communication.
     

      Where I work we have introduced SBAR type notification as our standard form of documentation for information coming into the ED, be that paramedic alerts or abnormal investigation results.

    We have also introduced it to our ED Notes as a summary page to aide handover between clinical teams and in our Clinical Decisions Unit at the end of protocols so that the referring clinicians can clearly outline their expectations for the patient









    Used correctly and aye there lies the rub, SBAR use help delivers safer patient care and also protects clinicians.

    I HIGHLY recommend considering using it.

    Information about SBAR can be found here- NHS Institute for Innovation and Improvement on SBAR









    Situation

    Missed C2 Fracture

    Background

    An elderly patient attended from his Nursing Home having fallen on to his face on concrete sustaining significant bruises to his face and head. He had quite marked dementia which made assessment difficult but he seemed to have good neck movement and complained of no localised pain there.

    X-rays were taken of his mandible which was deemed to be normal before a plan to admit to Med Eld was made.  The following day he was seen on the ward round and again had no neck pain and was deemed fit for discharge.

    He returned to the ED 3 days later as the nursing home staff felt he was more confused than normal.  He was noted to have no ‘neck tenderness’ before being sent for a CT of his head and brain.

    The CT confirmed facial fractures, small intra-cerebral haematomas and also showed an off ended PEG (C2) fracture with cord impingement.

    He was fitted in an Aspen Collar before transfer to Med Eld for conservative treatment

    Assessment


    The ED teams initial failure to diagnose the C2 fracture caused no serious harm to the patient however it certainly exposed him to risk and despite repeated ‘no neck pain documentations’ must have caused some him some additional discomfort

    Assessing any patient with decreased ability to communicate makes it harder to get things right first time, be that extremes of age, language barriers, intoxication or dementia

    Frail elderly people break more easily than you think.

    A fall banging the forehead /face is a classic mechanism for PEG fractures (hyperextension of the neck)

    They are VERY easily missed

    Recommendation

    Remember ‘the head bone is connected to the neck bone’  so any facial injury puts the neck at risk

    Have a lower threshold than normal for CT imaging of the neck in patients with the right history and decreased communication abilities
    Remember ’Steel’s rule of thirds’- at the level of C1 the spinal canal consists of 1/3 Cord, 1/3 Bone (peg of C2) and 1/3 space- so there may be no neurological signs (fortunately)

    Also remember Central Cord Syndrome can occur late in this group, even without a fracture CC Syndrome

    Remember to give good discharge advice with ‘triggers to return’ for patients or their carers


    Situation

    Opiate Overdose

    Background


    A 50 yr old lady was found face down on a golf course having apparently taken 200mg of oramorph . Paramedics gave her IM Naloxone on scene and on the way in (800mcg and 400mcg). On arrival at ED her GCS was 15 with normal observations but she did de-saturate off Oxygen

    She was seen immediately by a senior doctor and moved to a visible cubicle next to the nurses’ station on a monitor where she chatted to her family. The doctor was drawn into to resus to deal with other patients but came back approximately thirty minutes later to perform an Arterial Blood Gas (ABG). In that 30 minutes the pt had been cannulated, an ECG performed and was conversant with staff and relatives. The doctor noted that the pt was now very drowsy, with an ABG showing a pH of 7.2, CO2 of 8.38 and O2 of 12 (kPa on high flow oxygen)

    She was taken to resus where a naloxone infusion was commenced and BiPAP started before transfer to critical Care. She made an uncomplicated recovery and was discharged the following day.

    The case was reported as a potential SI in view of the patient’s deterioration, but subsequently downgraded on review of her care records

    Assessment



    There are many elements of good care;
    Good recording of pre-hospital SBAR
    Good nursing assessment with immediate discussion with a senior doctor
    Immediate review by the senior doctor
    Placement of the patient in a highly visible cubicle on cardiac monitoring

    What could have been done better?
    The treating doctor did not notice the first dose of Naloxone given by the paramedics was 800mcg

    Had they done so they may have considered starting an IV Infusion earlier or further bolus doses


    Recommendation



    Opiate overdoses should be cared for in a monitored highly visible environment with regular documented obs

    If obs cannot be measured regularly on a team the patient should be moved to resus

    Always read and document what treatment the patient has had BEFORE arrival. It can influence what you need to do

    BEWARE of re- narcotisation

    Naloxone has a much shorter half-life (30 to 80 minutes) than most opiates especially methadone (4- 8 hours analgesia, 8-59 hours elimination)

    Consider a naloxone infusion (BNF- 10mg (25 vials!)in 50mls of 5%dex)