Lack of coordinated information
Medication errors can easily be caused by information not being passed on at staff handover.
An elderly man called ‘Giovanni’ came into hospital with a lump in his bowel that needed investigation.
He was otherwise well and lived independently. He was expecting to live to an old age.
All Giovanni know was that he suffered from chronic constipation and stomach bloating. His GP was concerned it might be cancer and suggested he have further tests.
The Senior Doctor ordered a CT scan with contrast, to get a clear picture of the Giovanni’s bowel.
Because the dye used in CT contrast was know to be dangerous for people with existing kidney disease, the doctor ordered a pre scan blood tests, to check the his kidney function.
The blood test showed that the Giovanni’s kidney function was poor, he had chronic renal failure. But because this disease does not have symptoms until it is late stage, the man had no symptoms.
The Doctor told a Resident Doctors to write up a drug, to be given to Giovanni before he had his CT with contrast scan.
This drug was know to provide protection to damaging kidneys, from the damaging dyes used in CT with contrast scans.
The Resident Doctor wrote the drug up.
He then went looking for the nurse allocated to the patient, to make sure she gave Givoanni the drug.
The Doctor couldn’t find the right nurse. However he found one of the senior nurses on the ward.
The Resident Doctor repeated several times that it was very important this man have the drug, before his scan.
The nurse assured him that she would pass the message on.
In the meantime there was a change of nursing shift. The CT scan was cancelled.
The ward was very busy that evening, with a lot of post operative patients coming back to the ward.
Acute renal failure is a well known complication of procedures that involve iodinated contrast media. Despite this, contrast medium induced nephropathy accounts for about 12% of all cases of hospital acquired renal failure.
BMJ September 2006
A days after Giovanni had the CT with contrast, he became very unwell.
Urgent blood tests showed his kidneys had failed completely.
The doctors checked the drug chart and saw that the order for the drug to protect the man’s kidney had been written up, but not been given.
The doctors were extremely angry and confronted the Nurse Unit Manager who called up the nurse who had looking after the man that shift. She had given the patients his normal medications. But one off or ‘stat’ drugs were written on a different part of the drug chart. The nurse was from an agency. She didn’t even know to look at a different part of the drug chart.
The patient’s blood potassium levels and other waste products kept rising.
Within a week Giovanni urgently needed dialysis. The Renal team was called to assess him for hemodialysis. Due to his advanced age, they declined to accept him. Services were limited due to the costs of the program.
Giovanni deteriorated rapidly. His family were in shock. Giovanni became agitated and confused. He was referred to palliative care. Four weeks after the scan, Giovanni died from acute renal failure, secondary to a medication error.
While the staff were very sorry about the mistake, no steps were taken to prevent it from recurring.
Electronic drug charts were eventually introduced but there were as clumsy and awkward to use as paper charts.
Check lists were not introduced into radiology. Verbal handovers were never combined with electronic media to help reduce hand over errors.
© Wikihospitals 2014
Acute renal failure induced by contrast medium: steps towards prevention – BMJ September 2006
Literature Review: Medication Safety in Australia – August 2013