RMF Teaching Case M7-1 - Download
Mary Merchant, a RN who has been working with infectious disease patients for 15 years, is recognized as competent, careful and caring. She has supervisory and planning duties as well as her regular caseload, currently, five patients. Like most of her colleagues, Mary has a busy life outside her work. Today, she has an appointment with her son’s teacher to discuss his behavioral problems, so she hopes she won’t be asked to do a double shift.
Donnie Smith in Room 202b was admitted for treatment of pneumonia and is receiving IV antibiotics. As the last dose finishes, Mary goes to the medication room off the nurses’ station to get some heparin flush to clear the IV. Several days ago, one of the meds room’s overhead fluorescent lights went out and maintenance hasn’t gotten to it yet to fix it.
Mary reaches into the drawer where the heparin flush is kept and pulls out a vial. It’s hard to see it in this light, but she does this so many times a day it’s become a mechanical process. Mary’s thoughts drift to her meeting this afternoon at school: what’s going on with her son and what’s she’s going to do. She finds herself in the medication room wondering why she came in there in the first place. She suddenly remembers. The heparin for Mr. Smith.
As she picks up the vial, Dr. Grendle taps on the medication room window and asks her to join him for lunch. She says “sure” while wiping the top of the vial with an alcohol swab. She turns the vial upside down and draws out the liquid into the syringe. She puts the vial onto the counter and heads towards Mr. Smith’s room.
As Mary is disconnecting the empty antibiotic container from the IV and flushing the line, Mr. Smith complains that the flush stings much more than the antibiotic did. Mary says it will stop in a few seconds. A minute later Mr. Smith slumps over in the bed in cardiac arrest.
After her patient has been attended to, Mary rechecks the vial; it is not heparin flush, but concentrated potassium chloride in a vial similar in size and shape to the heparin. Looking from the top, one can’t tell the difference between the two.
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RMF Teaching Case M7-2 - Download
Dr. Veronica Josephs, a gastroenterologist, is treating 62-year-old Serena Vonce—who has a single transplanted kidney—for diabetes. Because Serena has had two catheterizations with contrast dye in the past week, he orders (via the computerized order entry system) the next catheterization without contrast dye for one week from the last one. This will give Serena time for rehydration.
The Radiology department, noting the delay but not the reason for it, arranges for the catheterization the following day. The radiologist determines the correct method for diagnosis, and the test is administered with contrast dye. That night, the patient is diagnosed with acute renal failure. Gradually, she recovers. Dr. Josephs identifies the near miss and institutes a root cause analysis (RCA).
The RCA identifies the following system flow:
A meeting is held among Radiology, Internal Medicine, and Information Systems to discuss the findings and develop solutions. They recognize that unaligned perceptions can introduce risk to the patient, for example, the ordering physicians may be unaware that the electronic system is programmed to include redundant patient info, thus truncating the patient’s history at one line (in this case, radiology did not have information about two recent cardiac catheterizations).
The departments institute regular ongoing channels of communication. The electronic system is amended to more clearly define the request and to create more accurate screens. The departments work out a better relationship and language to reflect the roles and language of physicians “ordering” tests and radiologists “performing” the orders.
RMF Teaching Case M7-3 - Download
In the 1800s, the DuPont chemical company owned gunpowder manufacturing plants which experienced frequent explosions. DuPont’s first safety efforts consisted of excluding metal that could cause a spark from the manufacturing floor; this proved ineffective in significantly reducing explosions. Next, they experimented with a variety of changes in the formula for the gunpowder they produced; this too failed to eliminate the safety problems.
Finally, in an effort to ensure a commitment to safety, DuPont had their managers' offices relocated to directly above the rooms where the gunpowder was made. The priority for safety was reinforced.
To measure, or demonstrate your own commitment to improving patient safety:
Source: NRF News
