Missed information at staff handover can easily lead to serious hospital errors
‘Hospitals are very complicated places’ – Unaccountable, Marty Makary.
An elderly man called ‘Giovanni’ came into a hospital to have an investigation of a bowel problem. He was otherwise well and lived independently.
Medication errors were the last thing on Giovanni’s mind. All he know was that he suffered from chronic constipation and stomach bloating and that his GP was concerned it might be cancer.
Simple check lists could save thousands of lives every year
The hospital doctor ordered a CT scan with contrast, to get a clear picture of Giovanni’s abdomen.
Because the dye used in CT contrast was know to be dangerous for people with existing kidney disease, the doctor ordered a blood tests, to check the patients kidney function.
The test showed that Giovanni’s kidney function was poor and he had chronic kidney disease.
Because this disease does not affect people until it is end stage, he had no symptoms and no idea of his condition.
The senior doctor told a resident doctors to write up a drug, to be given before the man had his CT with contrast scan.
This drug was know to provide protection from the damaging dyes used in 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 the drug.
The resident couldn’t find the right nurse. She was off the ward picking up a patient from theatre. 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 this would be done.
In the meantime the patients scan was cancelled. There was a change of nursing shift. The CT scan was cancelled several more times.
The ward was very busy that evening, with a lot of post operative patients coming back to the ward. Finally, late at night radiology called to say they were ready to take the man for his scan.
Another nurse was sent to escort the patient. She was not looking after this patient and had no idea about the drug being meant to be given before the scan.
A few days later Giovanni became very unwell.
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 patient’s kidneys had not been given.
The doctors were extremely angry and confronted the nurse looking after the man that shift. She had no idea about the drug, or why her patient was unwell. She had never seen the patient before.
The senior nursing staff were called in to explain. They realised the mistake and rang the night nurse to find out why she hadn’t given the drug before the scan.
In the meantime Giovanni was given a number of drinks to try and bring his blood potassium levels down. The drinks failed, and his blood potassium levels kept rising.
Within a week of being admitted to hospital for a straightforward scan, Giovanni was diagnosed with acute renal failure and urgently needed dialysis.
Treatment to fix errors is not always possible
The dialysis team was urgently called to assess Giovanni for hemodialysis. Due to his advanced age, they declined to accept him.
Services were limited due to the cost of the dialysis program.
He deteriorated rapidly, and was referred to palliative care. Four weeks after the CT scan, Giovanni died from acute renal failure.