International Journal for Quality in Health Care 14:519 (2002)
© 2002 International Society for Quality in Health Care
Every Defect is a Treasure |
Inadequate monitoring in the absence of a treatment protocol leads to an adverse outcome
A 77-year-old man is discharged from the hospital 30 minutes after removal of a surgical drain and dies en route to a family celebration.<typesetter: this is to be a 2-column layout, paragraphs in roman type on the left, italic on the right; paragraphs with like numbers should start at the same height on the page.>
<1>A 77-year-old male patient with a history of mild asthma undergoes surgery for removal of a retropharyngeal mass. Blood tests performed prior to the surgery reveal that the patient’s clotting time is slower than normal. However, the decision is made to proceed with the surgery, which is described as uneventful. Post-operatively 160 ccs of fluid drain from the surgical site over a 12-hour period, a relatively high volume of fluid for a case not violating any major blood vessels. In addition, references in the medical record covering the time from when the patient enters the recovery room until he reaches his room in the ward characterize the wound as ‘oozing’.
<1>Research shows that adverse events are more likely to occur in the operating room than in any other place in the hospital. The types of error that may occur include performance (technical error), preventive (error of omission), diagnostic (failure to use an indicated test), medication-related error, or systems errors (verbal communication in a risk situation). To enhance training, standardization of even the most common procedures using detailed checklists might help surgeons reduce technique-based complications and improve teamwork and communication skills. To that end, creating a genuine environment with teamwork and respect is crucial for learning.
No physician can be expected to remember every action item that needs to be addressed without some kind of system or prompt. Errors in follow-up are made despite the best of intentions. Where shared electronic medical records are in use, a system of automated reminders that will flag abnormal lab values (for example, as in this case, clotting times) would help alert others to problems.
<2>Three days following the surgery the attending surgeon and a resident, after several unsuccessful attempts, remove the drain from the surgical site. The patient is anxious to leave the hospital to attend a family gathering and is discharged from the hospital 30 minutes after the drain is removed. En route from the hospital to the gathering, the patient experiences difficulty breathing and loses consciousness. An ambulance is called, but after many unsuccessful attempts at intubation (notes in the medical record reveal a large hematoma in neck area) the patient is pronounced dead. Autopsy reveals a two-ounce blood clot at the surgical site with internal hemorrhage.
<2>Implementing key communication strategies to assure effective treatment planning is essential. In this regard, establishing and following protocols (an example in this case would be a period of observation after removal of a drain) have the potential for improving outcomes. In addition to having protocols in place, baseline knowledge of patient parameters (e.g. age, history of asthma, impaired clotting time, the amount of drainage) might help to determine the level of risk, thereby signaling the need for closer monitoring of the patient’s condition.
Adapted with permission by Kathleen Dwyer, MS,from Resource, September 2001. Resource is an audiotape publication of the Risk Management Foundation of the Harvard Medical Institutions, Cambridge, MA, USA. 
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