Young Physician Award, Winning Essays 2011

The team had just brought another life into this world kicking and screaming. The infant boy was delivered vaginally at term with no complications. As the room was cleaned up, the IV was hung and the team basked in the joy of the ecstatic family.

As things were wrapping up, the new mother began to complain about feeling warm and she appeared a little flushed. The doctors and nurses didn’t think it was too concerning, so they decided only to monitor her. Within minutes, she complained of nausea and minutes after that difficulty breathing. Less than ten minutes after her initial complaint of feeling warm, a resident was performing CPR on the patient while a code team was called.

When the patient was transferred to the intensive care unit, she had a serum magnesium level of 22 mEq/L.

The series of events that lead up to the patient’s cardiac arrest began in a boardroom. A decision was made to reorganize the layout of premixed IV medications in the Ob/Gyn ward. Previously the IV bags were arranged by drug, the decision was made to reorganize them by size. This lead to the one-liter bag of Pitocin being placed right next to the one-liter bag of magnesium. Changes to hospital policies and procedures are common, and should not provide difficulties to patient care, except in this instance; the change was never communicated to the staff. None of the doctors or nurses that evening knew a change in medication lay out was occurring.

A single misstep usually does not lead to patient harm; the system should have many fail-safes built in, but they were not evident that day. For easy distinction, the Pitocin bag was to have an additional bright green sticker while the magnesium back was to have a bright pink sticker. On the day of the incident, the only labeling the doctors and nurses saw was the black text on white background of the Pitocin and white text on black background of the magnesium.

Despite all of these failures, had any member of the staff checked the label before administering the drug, the adverse event could still have been prevented. The nurse administering the drug later recounted how routine it was… she has done this a million times before, so she just grabbd an IV bag from the same old spot and hung it and went about her remaining duties.

While the patient was coding, the team had tremendous tunnel vision. Protocol was yet again not followed, not a single person looked at the IV pole to double check what was hanging. The attending thought it was an amniotic fluid embolism, the team followed his direction. It was not until the patient was in the ICU and blood tests came back, that we even realized the patient had magnesium toxicity.

After the event, the hospital played the shame and blame game, and tried to brush all of it under the carpet. The only open and honest discussions were whether to even tell the patient about the events surrounding the incident and whether to fire the nurse that administered the medication or not. There was no debriefing of the staff. None of the attendings, residents or medical students were queried regarding the events of that evening by hospital administrators. The only quality improvements measures were done internally within the Ob/Gyn silo, with no contribution from nursing or pharmacy.

The nurse who administered the medication has been working in the unit for many years and is very well liked. She broke down in front of the attending that evening, sobbing, asking how she could have been so careless. Those present did their best to comfort her, but there was no other care for the providers. She heard people openly discussing whether or not she would be fired from her job.

I will always carry the pain that the patients’ family and the nurse who administered the medication for the rest of my life. I believe it all starts with open and honest communication, not only between the patient and providers, but also between the different silos within the hospital. To that end I have been working with other health professional students to create an interdisplinary leadership series. The goal is to break down the silo early in the careers of health care providers. Medical, nursing, public health, applied health and pharmacy students mingle and participate in joint activities with hopes that the cooperation will be carried into their practices.

Open disclosure after an adverse event is my true passion, though it is not enough. The information we gain not only needs to be disclosed to patients, but also used for quality improvement purposes. I am currently working with the Institute of Patient Safety Excellence at UIC on the 7 pillars grant. The institute is taking the combined full disclosure and quality improvement model from UIC and implementing it at multiple hospitals in the Chicago area.

This event has instilled in me a passion and a drive to always be open and honest, whether it is with my patients or with my fellow providers. I believe it is only a first step, but it is a giant step if everyone in the healthcare profession can take it to heart. I hope to be part of a generation of health care providers who will work together to instill a patient safety culture across the field of medicine.

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