BRIEFLY DISCUSS WHAT SHOULD HAVE HAPPENED IF GOOD PROCESSES WERE IN PLACE; WHAT WAS THE ORIGINALLY DESIGNED SYSTEM/PROCESS? WERE THERE BREECHES IN ESTABLISHED STEPS?
Part I: Case Description
Our case occurred at an urban, academic medical center with patient Mr. S, who was sent to PACU after a routine surgery. Standard post-operative orders include a patient-controlled analgesia (PCA) for his type of surgery. In the PACU, the RN started Mr. S on a Morphine PCA, 0.1 mg basal, 0.2 mg demand with a 10 minute lock out. Two RN’s checked the PCA when initiated, as per policy. His vital signs were stable, and his pain appeared to be well controlled.
At 16:16, Mr. S was deemed stable for transfer to the floor. The covering resident assessed him and changed his medication from Morphine to Dilaudid. The PACU nurse switched this medication immediately after receiving the syringe from pharmacy and another independent check was done. After speaking to the attending, the resident decided to discontinue the basal rate and called the PACU RN regarding the changes, but she replied that, although the computer still listed Mr. S in the PACU census, she had just transferred him to the new floor. The busy resident was called away to an emergency before he could contact Nursing on Mr. S’s new unit.
The new RN caring for Mr. S was not aware the basal rate order had been discontinued. Because he had verbally verified the PCA dosing during handoff from the PACU RN, he did not check the actual EMR for orders. The patient was stable, and the RN was busy with discharge teaching for a non-English speaking patient (no interpreter was on staff that day). There was no further bedside rounding that occurred on Mr. S for the remainder of his shift. Mr. S’s wife stayed with her husband for the afternoon and assured the RN that Mr. S was comfortable, saying “He hasn’t complained a day since we’ve retired, he’s tough like that. But I’m here for whatever he needs.” (However she noted later that he was very sleepy and sometimes would fall asleep mid-conversation.)
The Resident eventually called at 18:00 to confirm Mr. S’s pain was well controlled on this new dosing, but the RN assumed the MD was referring to the switch from Morphine to Dilaudid, as he was still unaware of any rate changes.
On this particular day, Mr. S’s RN was picking up an extra 4 hours on his shift, so he stayed on duty until 23:00. Nurse handoff was brief for Mr. S’s exhausted RN, as he had finally discharged his patient, gave report on another, and then quickly summed up Mr. S’s report outside the room. “He’s an easy one, a very nice older gentleman,” the outgoing RN said as he clocked out cheerfully at 22:45. At 23:30, the night shift RN came in to greet her patient and noticed that Mr. S was very difficult to arouse with a low respiratory rate. Additionally, Mr. S’s wife sat next to him on the bed, with the PCA demand button nearby. A quick set of vital signs revealed his pulse ox was <90%. She performed a thorough pain assessment on Mr. S, checked his PCA against the order and realized the error – basal dose was still running. She realized the wife may have also been delivering Mr. S unneeded (yet well intentioned) demand doses. The RN educated Mrs. S and quickly called the MD to report the change in vital signs (at this point, the covering night float resident was on duty and was also unaware that there had been any breakdown in communication on the previous shift.)
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