Anatomy of a Near Miss
Posted by Clark Venable on 11/9/2004
Medical errors are insidious. Many, many errors occur that do not lead to a bad outcome, but they are errors nonetheless. Given a different patient or set of circumstances, those same errors could result in injury, death, or at the very least less than optimal care. The following example serves to reinforce this point.
A thin, elderly woman is admitted the morning of her planned multi-level spinal laminectomy, instrumentation, and fusion. She is healthy, active, and appears younger than her stated age. She meets her anesthesiologist for the first time twenty minutes before the case. Upon review of her records, she appears to be free of cardia or pulmonary disease, but he notes laboratory results on the chart which indicate a macrocytic anemia (blood count of 30--normal is greater than 35 or so). The patient does not recall being told this before. No mention is made of this finding in the surgeon's history and physical examination, or elsewhere in the chart. Someone did think to do serum B12 and folate levels, both of which were found to be normal but no note is present to indicate the differential or planned workup. The finding is discussed with the surgeon and the case proceeds.
Error number one: the abnormal laboratory value should have triggered further evaluation. Some evaluation was attempted, but there was nothing in the chart to indicate by whome, or what their conclusion was. Significant blood loss is likely in this case. Starting with a lower hematocrit means less blood can be lost before a transfusion becomes necessary.
Error number two: the anesthesiologist should have cancelled this case due to a new anemia of unknown etiology. The severity of the anemia is such that a blood transfusion will almost certainly be needed. If time had been taken to evaluate and treat the anemia, the blood count may have risen sufficiently to reduce the likelihood of needing a transfusion. Even if the blood count could not be improved, directed donation or intraopoerative blood salvage techniques could have been used. Why didn't the anesthesiologist cancel the case? No good reasons, just all the usual ones. He was afraid the surgeon would be angry. He kne w the patient had been dealing with severe pain and was holding out just for this surgery.
Intra-operative blood loss was approximately 700 cc. Euvolemia was maintained with Hespan and lactated Ringer's solution. The patient was warm, urine output was good, and both blood pressure and heart rate were stable. Her hemoglobin near the end of the case was now 7, and a unit of blood was ordered from the blood bank. When no blood arrived within 30 minutes, the blood bank was called to inquire if there was a problem. No blood sample from the patient was available in the blood bank to cross-match bank blood against. A sample was immediately drawn into a red-top vial and sent. The case ends, patient is extubated successfully, and transported to the recovery room where her vital signs remain stable and urine output good. The anesthesiologist continues with other scheduled cases after giving report and asking the recovery room nurse to administer one unit of blood when it become available.
After another thirty minutes pass, the blood bank calls the recovery room to inform them that the sample was received in the wrong vial. The blood bank used to require a red-topped vial, but now want a lavender-topped vile (the former contains no anticoagulant, the later does). A phlebotomist is called to draw the new sample and the patient received a blood transfusion fully two hours after the anesthesiologist made the decision to administer blood.
Error numbers three through ten: 'what we have here is a failure to communicate.' There was a failure to communicate:
- that blood had not been drawn pre-operatively as ordered (even though the pre-op checklist indicated it had)
As an interesting aside, this was the first morning the nurses in the pre-op area were asked to use a computerized nursing record rather than their preferred paper method of charting.
- that the blood bank had no specimen to crossmatch blood against after receiving a call for blood.
- that a change had been made in what kind of specimen was needed for crossmatch.
- you can fill in the remainder.
The only reason this patient did not suffer harm from this incident is that she was physiologically very healthy. Imagine a patient with stable but significant coronary disease. That patient would not have tolerated a hemoglobin of seven so well. Imagine a more significant blood loss. It's better to be lucky than good. It's even better to be both.This example demonstrates what is so often true of medical misadventures: it is a series of events in combination which conspire against the practitioner and the patient to cause harm.
My response to this event is to draft a 'Go/No-Go' list. My personal decisions on whether to do a case is heavily influenced by what I know the surgeon reaction will be. I'm not saying that's the right reaction, mind you. It's just my reaction (in wanting to please people as I do). A Go/No-Go list is similar to what NASA uses to decide whether or not to launch a space craft. If any item is 'No-Go' the launch is scrubbed. On my anesthesia Go/No-Go list, if I discover an item in a patient chart that's on my list, launch is scrubbed and the case is rescheduled. New, unexplained anemia is certainly on that list, especially in light of a surgery likely to result in significant blood loss. I need to spend some serious time adding to this list. I'll post it as a work in progress.
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