CASE STUDY IN CASE STUDY IN COMBINED SYSTEMS COMBINED SYSTEMS

AND INDIVIDUAL AND INDIVIDUAL FAILUREFAILURE

Case represents an example Case represents an example based on real case. Some details based on real case. Some details have been changed and case de-have been changed and case de-

identified to preserve patient identified to preserve patient confidentialityconfidentiality

Ethan Cumbler M.D.Assistant Professor of Medicine

Hospitalist SectionUniversity of Colorado Hospital

2007

CASE OF THE TRAUMATIC CASE OF THE TRAUMATIC URINARY CATHETER URINARY CATHETER

REMOVALREMOVAL 86 y/o male with hx 86 y/o male with hx

of CHF, Afib, and of CHF, Afib, and Dementia presents Dementia presents with increased with increased lower extremity lower extremity edema and SOB. edema and SOB. Documented to be Documented to be non-compliant with non-compliant with medications for medications for months.months.

PMHPMH CHFCHF AfibAfib HypothyroidHypothyroid OsteoporosisOsteoporosis DementiaDementia Parkinson’sParkinson’s Urinary Urinary

IncontinenceIncontinence

CASECASE

AllergiesAllergies-NKDA-NKDA

MedicationsMedicationsNoncompliant with:Noncompliant with: LinsinoprilLinsinopril AmiodaroneAmiodarone CarvedilolCarvedilol FurosemideFurosemide WarfarinWarfarin AsprinAsprin Calcium-Vit DCalcium-Vit D AlendronateAlendronate Carbidopa/levodopaCarbidopa/levodopa LevothyroxineLevothyroxine

Social HxSocial Hx Lives with wife who Lives with wife who

also has significant also has significant dementia. APS dementia. APS involved in his care involved in his care multiple occasionsmultiple occasions

Hospital Course- Day 1Hospital Course- Day 1

Admit to Cardiology Service. For Admit to Cardiology Service. For CHF exacerbation due to CHF exacerbation due to medication noncompliance. medication noncompliance. Treating with IV furosemideTreating with IV furosemide

Indwelling urinary catheter Indwelling urinary catheter ordered.ordered.

Documented need for strict Is + Documented need for strict Is + Os along with presence of stage II Os along with presence of stage II sacral skin breakdown.sacral skin breakdown.

Hospital Course- Day 3Hospital Course- Day 3

Care transferred to Internal Medicine service.Care transferred to Internal Medicine service. Patient transitioned to oral furosemidePatient transitioned to oral furosemide Medicine team is post-call and discusses Medicine team is post-call and discusses

patient on “sit down rounds” (not at bedside). patient on “sit down rounds” (not at bedside). No mention of urinary catheter on roundsNo mention of urinary catheter on rounds

Medicine Attending #1 notes presence of Medicine Attending #1 notes presence of catheter while rounding alone later in day. catheter while rounding alone later in day. Verbal order to nurse to remove catheter.Verbal order to nurse to remove catheter.

At end of day Attending #1 discusses plan to At end of day Attending #1 discusses plan to remove catheter with Resident. Neither remove catheter with Resident. Neither Attending #1 nor Resident write order to Attending #1 nor Resident write order to remove catheter.remove catheter.

Nurse forgets to remove catheter in response Nurse forgets to remove catheter in response to verbal order by Attending #1.to verbal order by Attending #1.

Hospital Course- Day 4Hospital Course- Day 4

Attending #1 is no longer on service Attending #1 is no longer on service (scheduled switch at end of week).(scheduled switch at end of week).

Resident has day offResident has day off Resident and Attending do not Resident and Attending do not

communicate intended catheter removal communicate intended catheter removal during check-outduring check-out

Intern not aware of plan to remove Intern not aware of plan to remove cathetercatheter

Intern and Attending #2 do not discuss Intern and Attending #2 do not discuss presence of urinary catheter or plan for presence of urinary catheter or plan for it’s removalit’s removal

Hospital Course- Day 5Hospital Course- Day 5

Intern has day offIntern has day off Resident returns to service. Resident returns to service.

Notes presence of urinary Notes presence of urinary catheter and assumes that it was catheter and assumes that it was removed but then replaced for a removed but then replaced for a medical indication for which medical indication for which resident is not awareresident is not aware

Hospital Course- Day 6Hospital Course- Day 6

Patient wakes in the middle of the Patient wakes in the middle of the night confused. Gets out of bed and night confused. Gets out of bed and walks towards bathroomwalks towards bathroom

Catheter bag is attached to opposite Catheter bag is attached to opposite side of bed, traction rips it (with bulb side of bed, traction rips it (with bulb inflated) out of penis causing urethral inflated) out of penis causing urethral tear and significant bleedingtear and significant bleeding

Pt had bleeding for 3 days requiring Pt had bleeding for 3 days requiring aspirin and heparin prophylaxis to be aspirin and heparin prophylaxis to be held. Urology consulted. Hct drops.held. Urology consulted. Hct drops.

One week after discharge patient was One week after discharge patient was readmitted for transfusionreadmitted for transfusion

STRUCTURED STRUCTURED ANALYSIS OF MEDICAL ANALYSIS OF MEDICAL ERRORERROR Use (Use (Systematic Analysis of a Medical Error Systematic Analysis of a Medical Error

form to guide discussion)form to guide discussion)

Step 1Step 1

Adverse event, Medical error, Adverse event, Medical error, CausationCausation

Was There an Adverse Event?Was There an Adverse Event? Yes. A traumatic removal of an Yes. A traumatic removal of an

unnecessary urinary catheter represents unnecessary urinary catheter represents an adverse eventan adverse event

Was there a Medical Error?Was there a Medical Error? Yes. The failure to remove unnecessary Yes. The failure to remove unnecessary

urinary catheter despite plan to do so urinary catheter despite plan to do so represented a medical errorrepresented a medical error

Were the two related?Were the two related? Yes. In this case the medical error Yes. In this case the medical error

directly lead to the adverse event.directly lead to the adverse event.

Step 2Step 2

Were There Systems Were There Systems Issues Which Issues Which

Contributed to This Contributed to This Error? Error?

-Communication-Communication-Information management-Information management-Technology-Technology-Supervision-Supervision-Workload-Workload-Human resources support issues (staffing)-Human resources support issues (staffing)

Systems issuesSystems issues CommunicationCommunication

Breakdown in intra-team communication based Breakdown in intra-team communication based on failure to discuss plan of care during team on failure to discuss plan of care during team rounds and fragmented communication of plan rounds and fragmented communication of plan to remove catheter with some but not all to remove catheter with some but not all members of the care team. members of the care team.

Failure to sign-out elements of care during Failure to sign-out elements of care during transitions off service.transitions off service.

Use of verbal orders- a form of communication Use of verbal orders- a form of communication with nursing prone to failures and with nursing prone to failures and miscommunicationmiscommunication

Diffusion of responsibility- Attending did not Diffusion of responsibility- Attending did not write order believing that resident would do so. write order believing that resident would do so. Resident assumed Attending had already written Resident assumed Attending had already written order.order.

Systems issuesSystems issuesInformation ManagementInformation Management Check-out system not formalized to Check-out system not formalized to

include plan of care for items such as include plan of care for items such as urinary catheters.urinary catheters.

Computerized nursing record tracks Computerized nursing record tracks urinary catheter presence but lacks urinary catheter presence but lacks connection to physician accessed connection to physician accessed portion of electronic medical record. portion of electronic medical record. Since removal of urinary catheters is a Since removal of urinary catheters is a physician-driven active process this physician-driven active process this removes opportunity for increased removes opportunity for increased physician awareness and prevents physician awareness and prevents electronic prompts to the physicians for electronic prompts to the physicians for removal.removal.

Systems issuesSystems issuesTechnologyTechnology

While decidedly low tech, the design of current While decidedly low tech, the design of current indwelling urinary catheters predisposes to indwelling urinary catheters predisposes to this form of urethral trauma.this form of urethral trauma.

Use of condom catheter rather than indwelling Use of condom catheter rather than indwelling catheter presents less risk of traumatic injury catheter presents less risk of traumatic injury (assuming the goal is strict Is+Os or skin (assuming the goal is strict Is+Os or skin protection rather than obstructive uropathy)protection rather than obstructive uropathy)

The design of the urinary catheter which The design of the urinary catheter which encourages it to be attached to bed rather encourages it to be attached to bed rather than the patients leg creates a form of single than the patients leg creates a form of single point restraint which may induce injury when a point restraint which may induce injury when a patient with dementia tries to get out of bed.patient with dementia tries to get out of bed.

Systems issuesSystems issuesSupervisionSupervision

No significant issuesNo significant issues

Systems issuesSystems issuesWorkloadWorkload

Nursing had multiple patients Nursing had multiple patients with active issues on day of with active issues on day of verbal order to remove catheter. verbal order to remove catheter. This likely contributed to nurse This likely contributed to nurse forgetting to remove catheter. forgetting to remove catheter. Low priority request easy to Low priority request easy to forget without reminder from forget without reminder from written orderwritten order

Systems issuesSystems issuesHuman ResourcesHuman Resources

Staffing model failed to preserve Staffing model failed to preserve continuity of team. Both continuity of team. Both Attending and Resident went off Attending and Resident went off service on same day. Multiple service on same day. Multiple transitions between teams during transitions between teams during short patient hospitalization.short patient hospitalization.

Step 3Step 3

Which Type of Individual Which Type of Individual Error Occurred?Error Occurred?

Knowledge basedKnowledge based- mistake from - mistake from inadequate or incomplete information inadequate or incomplete information or base of knowledge or base of knowledge

Skill basedSkill based- performance error. Not - performance error. Not doing the action which was intended. doing the action which was intended. We think of this as a “slip” We think of this as a “slip”

Rule basedRule based- the incorrect - the incorrect application of the information. We application of the information. We think of this as a “Judgment failure” think of this as a “Judgment failure”

Step 3Step 3

Which Type of Individual Which Type of Individual Error Occurred?Error Occurred?

Skill basedSkill based-- The request to remove catheter The request to remove catheter

was forgotten by nurse who was forgotten by nurse who received the verbal order (nurse received the verbal order (nurse became distracted by other tasks became distracted by other tasks and forgot to do so in absence of and forgot to do so in absence of written prompt)written prompt)

Step 4Step 4

List Heuristic Failures List Heuristic Failures Leading to Individual Leading to Individual

Judgment ErrorJudgment Error

There was no judgment error and thusHeuristics failure does not apply to this case

Step 5Step 5

What Level Harm Occurred As What Level Harm Occurred As a Result of The Adverse a Result of The Adverse

Event?Event?

1- No harm, error identified prior to affecting 1- No harm, error identified prior to affecting patientpatient2- Minor temporary harm2- Minor temporary harm3- Minor permanent harm3- Minor permanent harm4- Major temporary4- Major temporary5- Major permanent5- Major permanent6- Death6- Death

HarmHarm

Major temporary harmMajor temporary harm Bleeding sufficient to require Bleeding sufficient to require

transfusion represents a major transfusion represents a major adverse event but the patient did adverse event but the patient did not suffer permanent injurynot suffer permanent injury

Step 6Step 6

What Would You Disclose What Would You Disclose In This Case?In This Case?

In this case the fact of the urethral In this case the fact of the urethral trauma due to the patient trauma due to the patient accidentally pulling out catheter in accidentally pulling out catheter in the night was disclosed but the the night was disclosed but the medical error causing the catheter medical error causing the catheter not to be removed was not not to be removed was not discussed.discussed.

It would be easy, but not ethically It would be easy, but not ethically appropriate, to pretend that no appropriate, to pretend that no error had occurred. error had occurred.

Step 6Step 6

DisclosureDisclosure It would be appropriate to explain to It would be appropriate to explain to

patient/family that the team had intended to patient/family that the team had intended to remove catheter but that this had not actually remove catheter but that this had not actually occurred during the transitions over the weekend. occurred during the transitions over the weekend. The patient had become confused in the middle of The patient had become confused in the middle of the night and pulled the catheter out causing the night and pulled the catheter out causing injury (facts of the case). Since the plan was to injury (facts of the case). Since the plan was to remove the catheter it is appropriate to express remove the catheter it is appropriate to express regret that this occurred and an expression such regret that this occurred and an expression such as a “wish statement”. “I recognized that with his as a “wish statement”. “I recognized that with his confusion he is at increased risk for this sort of confusion he is at increased risk for this sort of event. There was a good reason for the catheter event. There was a good reason for the catheter to be placed but I wish that I had removed it to be placed but I wish that I had removed it earlier.”earlier.”

A straightforward apology is appropriate along A straightforward apology is appropriate along with an explanation of how the error will change with an explanation of how the error will change your practice to prevent this in the futureyour practice to prevent this in the future

Disclosure will be discussed in detail in the third Disclosure will be discussed in detail in the third seminar.seminar.

Step 7Step 7

What Steps Could be What Steps Could be Taken to Prevent This Taken to Prevent This From Occurring in The From Occurring in The

FutureFuture

Small group break-away sessions.Each group should be assigned anelement contributing to the medical error

Potential StepsPotential StepsCommunicationCommunication

Bedside team rounding decreases chance Bedside team rounding decreases chance that issues such as urinary catheter use will that issues such as urinary catheter use will not be noticed and discussed in the plan.not be noticed and discussed in the plan.

Team rounds later in the day would prevent Team rounds later in the day would prevent fragmentation of communicationfragmentation of communication

Creation of checklist of items to be Creation of checklist of items to be addressed on every patient in rounds addressed on every patient in rounds decreases chance that multiple necessary decreases chance that multiple necessary elements will be missed (catheters, elements will be missed (catheters, intravenous lines, DVT prophylaxis, skin care intravenous lines, DVT prophylaxis, skin care ect)ect)

Avoid verbal orders unless in emergencyAvoid verbal orders unless in emergency Clear delineation of responsibilities for who Clear delineation of responsibilities for who

on a team will write orderson a team will write orders

Potential StepsPotential StepsHuman ResourcesHuman Resources

Personnel turnover is unavoidable Personnel turnover is unavoidable but certain staffing models create but certain staffing models create more turnover than others. more turnover than others. Staggering days off to prevent all Staggering days off to prevent all senior members of the team from senior members of the team from taking the same day off taking the same day off decreases risk of discontinuity.decreases risk of discontinuity.

Potential StepsPotential StepsInformation ManagementInformation Management

Change in system of care such that Change in system of care such that multiple members of patients care multiple members of patients care team (physicians and nursing) are team (physicians and nursing) are empowered to remove urinary empowered to remove urinary catheterscatheters

Creation of new system to remind team Creation of new system to remind team that urinary catheters are in place. that urinary catheters are in place. Could be electronic in conjunction with Could be electronic in conjunction with I.T. department or handwritten I.T. department or handwritten reminders in chart. Would need reminders in chart. Would need interdisciplinary and administration interdisciplinary and administration buy-in to institute this potent QI step.buy-in to institute this potent QI step.

Potential StepsPotential StepsTechnologyTechnology

Preventive measures to decrease chance Preventive measures to decrease chance of demented patients from wandering. of demented patients from wandering.

Assessment of wandering risk/impulsivity Assessment of wandering risk/impulsivity for patients with dementia. Use of bed for patients with dementia. Use of bed alarms for those at high risk.alarms for those at high risk.

Catheter attachment to leg rather than Catheter attachment to leg rather than bed for patients at high riskbed for patients at high risk

Use of condom catheters for patients with Use of condom catheters for patients with dementia who have indication for catheter dementia who have indication for catheter which does not require indwelling formwhich does not require indwelling form

Next StepNext Step

Each small group reports back its Each small group reports back its potential solutions. The entire potential solutions. The entire group then examines solutions to group then examines solutions to determine which are most determine which are most feasible and have greatest feasible and have greatest potential to come up with an potential to come up with an action plan for a QI project.action plan for a QI project.