Case Summary
The case tells the story of Robin Lowe, a 24-year-old pregnant woman, and her mother, Glenda Rogers. Glenda is an experienced professional with specific knowledge of obstetric nursing (Rogers, 2016). At the time of the incident, her daughter, Robin, was eight months pregnant, and she went to the hospital as her chronic immune condition worsened.
During such periods, Robin could not eat without throwing up and required nutrients to be received directly into the bloodstream. At the hospital, doctors wanted to put her on total parenteral nutrition (TPN), which is administered intravenously (IV) (Rogers, 2016). However, the nurse used an enteral feed – a type of food that should only be injected into the gastrointestinal tract – for the IV line. As a result, Robin’s heart received high levels of fat, and she and her unborn child died.
Risks
The event posed significant risks for the patient, her family, providers, and the hospital. The physical risks for the patient were immeasurable – she passed away after one day in the hospital. Using an enteral feed with the IV line exposed, the patient was at immediate risk of death, as the thick mixture should not be administered into the blood.
Additionally, the patient did not receive pain-alleviating medication and was not listened to when she talked about experiencing pain. The emotional risks were similarly devastating for the patient and her family. The patient had a young son who just turned three years old (Rogers, 2016). Although Robin was used to her condition and did not fear for her life, in the end, the whole family was shocked to lose her. Providers making these mistakes could suffer emotional damage as well.
The financial risks of this incident can be significant for the hospital and the family. Robin’s husband lost a partner, who likely had another income stream to support the household. As he has a son, such changes in the financial situation may devastate the family’s well-being. Providers and the hospital are also exposed to potential financial dangers, as this case exposes them to liability.
Moreover, the facility may lose clients or experience negative feedback from the mass media. Finally, the organizational risks of the event are that its practice will not improve or that new problems will arise. The errors occurred due to the lack of attention and communication, and the clinic may continue experiencing similar events.
NPGS Goal
The Joint Commission has recommendations for hospitals to prevent these accidents. The most suitable goal is to improve the safety of medication use – in particular, the goal is to verify all labels verbally and visually by two individuals (The Joint Commission, 2023). In this case, the nurse did not question the fluid’s packaging, although the writing marked that it could not be used with an IV. Thus, no verification was done to ensure the solution was right for the patient.
Chain of Events
It is unclear who requested the patient’s feed. As the departments responsible for enteral and IV solutions differ, the first mistake must have happened during the ordering step. The disaster could have been stopped if several professionals had verified the order.
Second, the nurse administering the mixture did not properly read the labels – additional checking could have prevented the following events. Finally, healthcare providers – nurses, doctors, and anesthesiologists – did not listen to the patient or her mother, which led to the enteral feed being administered for several hours. Paying attention to the patient’s concerns could have helped to stop the IV quicker.
Human Factors
Human factors theory discusses how people are likely to make mistakes. Tubing misconnections may result from people not paying attention to the label and the differences between IV solutions and enteral mixtures. The design of the bags for solutions without tubing increases the risk of human error, as it leaves the decision to the person (Escrivá Gracia et al., 2019). Bags with tubing are more ergonomic as they decrease the danger of using incorrect medication. Therefore, the hospital may significantly lower the risk of such errors, as it will become impossible for nurses to pick up the wrong drugs.
Healthcare Professionals as Patients of Relatives
In this case, the patient’s mother is an experienced obstetrical nurse. However, in her story, she recalls not questioning anyone’s incorrect actions. Then, when she started to ask questions, she was ignored and dismissed. When acting as a patient or a family member, healthcare professionals may face the same obstacles as other people who visit a hospital.
The lack of patient-centered care and patient involvement in the process limits individuals’ authority and autonomy in treatment (Kokorelias et al., 2019). Caring professionals assume a position of power, and their actions are viewed as beneficial to the patient. Thus, even experienced providers may not trust their judgment and fail to question potential risks.
Just Culture
The concept of just culture shifts the blame from one person to an organization’s system. In the case of Robin, the hospital’s culture can be described as dismissive, inattentive, and not patient-centered. Only the nurse who administered the solution faced the consequences, while the organization did not experience any adverse outcomes.
According to Just Culture, the hospital has to review its system (Barkell & Snyder, 2021). The nurse and other professionals should conduct a root-cause analysis to determine what led to the incident. Accountability involves the whole organization, including the administration. All members should undergo education and create a new system to reduce medical errors.
References
Barkell, N. P., & Snyder, S. S. (2021). Just culture in healthcare: An integrative review. Nursing Forum, 56(1), 103-111. Web.
Escrivá Gracia, J., Brage Serrano, R., & Fernández Garrido, J. (2019). Medication errors and drug knowledge gaps among critical-care nurses: A mixed multi-method study. BMC Health Services Research, 19(1), 1-9. Web.
The Joint Commission. (2023). National patient safety goals®, effective July 2023 for the hospital program. Web.
Kokorelias, K. M., Gignac, M. A., Naglie, G., & Cameron, J. I. (2019). Towards a universal model of family-centered care: A scoping review. BMC Health Services Research, 19, 1-11. Web.
Rogers, G. (2016). Not for IV use: The story of an enteral tubing misconnection. In J. Johnson et al. (Eds.), Case studies in patient safety: Foundations for core competencies (pp. 232-245). Jones & Bartlett Learning.