So I’m finally watching the DVR-ed episode from March 10, 2009 that gave widespread exposure to the issue of medical mistakes. Oprah began the show by citing the statistic that errors cause more deaths than “breast cancer, AIDS, and car accidents combined.” This is not hyperbole.
Dr. Oz was on to talk about this issue for the first time on Oprah’s show (where has he been on this?). Yes, 100,000 lives per year.
Dennis Quaid and his wife Kimberly appeared on the show discussing the incident that could have killed his newborn twins, something I’ve blogged about here (and see some video from Oprah here). They recounted the story of how the twins were mistakenly given adult doses of blood thinner (10,000 times the dose they needed) TWICE. Not once, but on two separate occasions. The original focus in the story was “a nurse” gave the wrong doses… it’s not fair to pin the blame only on the nurse who administered the dose. What in the system allowed this wrong mediation to even get that far?
The hospital was, unfortunately, using the OLD inventory (the similar blues) rather than using the NEW inventory from the vendor that had better error proofing because of different colors and different methods for opening the vial. The hospital chose saving some money (not just throwing away or donating the old stock) over preventing the problem. See the 2nd picture for the new packaging — see how much harder it would be to make a mistake?
People knew about the look-alike packaging problem in 2006. Why didn’t Cedars Sinai take more preventative action before this problem occurred in late 2008?
Early in the show Dennis was talking about his lack of vigilance, that he expected that hospitals take care of you, that things will be OK, and that “people know what they’re doing… but mistakes happen.”
In situations like this, the people “know” what they’re supposed to do (give the right dose), but errors occur due to systemic failures and bad processes.
In talking about the incident, Dennis said that maybe it happened for a reason, that this can increase awareness and help get this problem solved. Amen to that. Any episode like this should drive process improvement and error proofing work at Cedars Sinai and every hospital.
Dennis suggested “computerized record keeping and bar code scanning” as a solution, which probably shows our American bias toward technology solutions. Dr. Oz pointed out (correctly) that we use a 19th century tool (a pen) in a 21st century medical system. He states that these technology solutions do help. But would they prevent EVERY incident? Not if nurses are clever enough to find ways to work around the bar coding systems when they are overwhelmed and pressed for time. This is a management/process problem, not just a technology problem. It’s naive to think that technology alone can solve this problem.
Quaid went back to Cedars-Sinai, with the Oprah cameras, and met with the Chief Nursing Officer, who said the overdose incident was “life changing” for her and her nurses, that “there was a lot of crying, a lot of hand-wrenching.” OK, that proves that people care, nobody doubts that. Nobody WANTS to make an error like this, but the systems failed the nurses. Crying and feeling bad isn’t enough when they could have been more proactive to improve their systems, learning from the Indianapolis case and other previous incidents. Where was the hand wringing when they realized this COULD happen at Cedar Sinai? Did they read the news about the Indianapolis case from 2006 and think “well we’re better, it couldn’t happen here”?
The CNO said this incident “served as a catalyst to find ways to prevent these errors.” That’s good.
The timeline that actually occured:
- 2006: Heparin overdose kills 3 babies in Indianapolis
- 2008: Heparin overdose severely harms the Quaid twins
- 2008: Cedars Sinai staff feel bad and begin improvement
- 2009: Oprah episode
It’s too bad the timeline wasn’t this:
- 2006: Heparin overdose kills 3 babies in Indianapolis
- 2006: Cedars Sinai staff recognize systemic risk and improve their processes
- 2008: Quaid twins are not overdosed
- 2009: No Oprah episode
How did the incident occur?
- Pharmacy tech made an error and put large dose Heparin in the same bin as small doses (see picture).
- The nurse grabbed a bottle out of the bin without checking the label (Quaid pointed out that the colors of the bottles are very similar, so they’re hard to tell apart)
Since the incident, Cedars Sinai has implemented a bar code system (as pictured). Their medical cabinets (commonly found in hospitals, this is not cutting edge technology) will “only dispense the dose that’s been ordered). But what if someone mis-loads the cabinet?
Quaid said “if this system had been in place when our kids were here, I don’t think this could have occurred.” There are still holes in these systems, the technology isn’t perfect error proofing because we still rely on people properly following processes. There’s still a risk that staff cut corners and managers need to be aware of that possibility. Managers need to audit the process and make sure workarounds aren’t being employed, communicating consistently about how important it is to follow the process. Then, the managers have to make sure that people have time to do things the right way (by having correct staffing levels and by eliminating waste in the process so nurses don’t fall behind in their work because they’re running around searching for tools and equipment).
During their demonstration, Quaid and Oprah inadvertantly nearly showed one of the workarounds — scanning an extra bar code label that was NOT on a patient’s arm. He was struggling to put the bar code on Oprah, so Quaid pulled the label toward Dr. Oz. (click any picture for a larger version)
To the credit of Dr. Oz, he prompted Quaid to properly demonstrate it by sort of putting the wrist band around Oprah’s wrist. Dr. Oz demonstrated the signal that would be given by the technology if he tried scanning a med for which no order appeared, a med that could have made her collapse.
Dr. Oz states that hospitals that have implemented systems like the one he demonstrated have gotten errors of the type that harmed the Quaid twins down to ZERO.
After the demo, Quaid also correctly pointed out some of the human factors:
- Nurses who are working 24 hour shifts
- They have a lot of patients
So errors occur. “Human error is part of the process,” said Quaid, so systems like this bring down the number of episodes. But will it really become ZERO if we don’t have good process controls and error proofing?
I wish there had been more focus in the discussion about process and management, not just technology. I will applaud Quaid and Oprah (and Dr. Oz) for trying to increase awareness. Now we just need the right countermeasures and a full set of process and technology countermeasures, both.
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