Treatment errors:
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Cardiac arrest from hyperkalemia | Difficult to distinguish potassium solutions of different strength | Protocol for administration of IV potassium. High concentrations limited to pharmacy. |
Respiratory depression from excessive narcotic dosing during conscious sedation | Inadequate supervision of medical trainees | Guidelines for the use of conscious sedation on general care units developed; identification of patients as high risk (i.e. sleep apnea) |
Aspiration pneumonia or pneumothorax after feeding tube insertion | Inadequate supervision of medical trainees | Dedicated team to insert small bore feeding tubes. |
Respiratory depression from excessive narcotic dosing with PCA | PCA pumps may be used by non-intended personnel (family) | Protocol for PCA education laminated on cards and placed on equipment |
Respiratory distress from hypoxia during transport | Oxygen tanks not checked before potentially long transport excursions | Oxygen tank exchange protocol |
Pneumothorax and other injuries from placing central venous catheter | Inadequate supervision of medical trainees, particularly during offshifts | Certification program for bedside procedures. Supervision available 24/7 |
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Diagnostic errors
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Cardiopulmonary arrest, various etiologies from delays in treatment | Ambiguous physician in charge | Objective criteria for MET activation |
Cardiopulmonary arrest, various etiologies from delays in treatment | Difficult to obtain ICU bed when hospital census is high | New MD position established (Resource Intensivist) responsible for triage within and among ICUs |
Delay in first shock during cardiopulmonary arrest | Crash carts stocked in inconsistent or incomplete manner | Standardized crash carts throughout the facility. |
Exsanguination from delay in blood availability | Blood products difficult to access quickly outside emergency department | Developed mechanism for obtaining large volumes of unmatched blood |
Bradycardia/asystole from delay in pacemaker placement | Permanent pacemaker placement considered a low priority consult | Initiated dialogue with cardiology that resulted in more accurate triaging |
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Prevention errors
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Inadequate surveillance for mucus plugging and other complications in tracheostomy patients | Non-surgical floors may be staffed by personnel with little familiarity with tracheostomy care | Protocol delineating schedule for tracheostomy surveillance by respiratory therapists |
Inadequate surveillance for rebound hypoglycemia following treatment of glucose or potassium abnormalities | Danger of hypoglycemia after IV insulin is underappreciated by hospital staff | Protocol describing frequency of monitoring after insulin boluses are administered |
Inadequate surveillance for medical deterioration in patients receiving radiology tests | Patients in radiology department not supervised by medical personnel | Pulse oximetry monitoring during radiology tests/procedures with MET activation if alarm |
Inadequate surveillance for medical deterioration in patients in transport | Patients in transport not supervised by medical personnel | Pulse oximetry monitoring during transport with MET activation if alarm |
Deaths and colectomies from iatrogenicC difficile exposure | Excessive broad spectrum antibiotic use;inadequate infection control | C difficile task force and antibiotic management team |
Fractures, subdural hematomas from falls in demented elderly | Restraints, no supervision, unpadded environment | Falls task force |
Fractures from falls in elderly using automatic doors | Doors not clearly marked and operate too fast for elderly patients | Automated messages of door use, reduced speed of automatic doors |