AFT2 Task 2 Sentinel Event Root Cause Analysis Example

A Potassium of 7.1 That Waited Two Hours: Root Cause Analysis and Corrective Action Plan for a Cardiac Arrest After a Delayed Critical Result at a Composite Hospital

Student Name

Leavitt School of Health, Western Governors University

AFT2: Accreditation Audit, Task 2

Course Instructor

Month Day, Year

A Potassium of 7.1 That Waited Two Hours: Root Cause Analysis and Corrective Action Plan for a Cardiac Arrest After a Delayed Critical Result at a Composite Hospital

The Sentinel Event

Mr. Walter Brooks, a composite patient aged 68 whose kidneys functioned at stage 4 and who also had heart failure, came to a medical unit at Bayview Community Hospital with a leg infection. He took lisinopril and spironolactone, both of which can raise potassium. He was not on a cardiac monitor.

At 12:52 a.m. the laboratory resulted a potassium of 7.1 mmol/L, a critical value. At 12:58 a laboratory technologist called the unit. The unit secretary answered, wrote the value on a note and told the charge nurse, who was at a rapid response call on another patient. Mr. Brooks's nurse received the message at 1:40 a.m. and paged the covering hospitalist through the answering service at 1:45. The hospitalist, who was responsible for the whole hospital overnight and did not know the patient, called back at 2:20, suggested the sample might be hemolyzed and ordered a repeat test. The repeat was drawn at 3:10. At 3:35 Mr. Brooks was found in cardiac arrest. After nine minutes of resuscitation his heart restarted, and he spent the following week recovering in intensive care. The arrest followed a delay in treatment and caused severe temporary harm, which placed it within the hospital's definition of a sentinel event.

Root Cause Analysis Team

The patient safety officer facilitated the analysis. The team included the laboratory director, the medical unit's nurse manager, the hospitalist medical director, a clinical pharmacist, the director of information systems and a risk manager, with the chief medical officer as executive sponsor. None of the people directly involved in the event served on the team, but each was interviewed, so that the analysis drew on their knowledge without placing them in the position of judging their own actions.

Personnel Present and Their Responsibilities

The laboratory technologist was responsible for reporting the critical result to a licensed caregiver and obtaining a read-back. The unit secretary answered the phone but, under hospital policy, was not authorized to accept critical results. The charge nurse was responsible for coordinating the unit and was the backup for urgent communication. The patient's nurse was responsible for assessing him and notifying the physician. The covering hospitalist was responsible for evaluating critical results and ordering treatment overnight. The rapid response team was available to any staff member concerned about a patient but was not called for Mr. Brooks until the arrest.

Barriers to Effective Interaction

The interviews revealed four barriers. First, the result traveled through an unauthorized receiver, so it arrived late and without a read-back. Second, the charge nurse was occupied, and there was no rule for what should happen when the backup was unavailable. Third, the answering service added a step between the nurse and the physician, and the nurse did not include the patient's medications or kidney function in her page. Fourth, and most important, the nurse was uneasy about the plan to repeat the test but did not call again or activate the rapid response team. She said she did not want to seem to question an experienced physician in the middle of the night.

That hesitation is well documented. A review of 26 studies found that health professionals' willingness to speak up is shaped by the perceived risk to the patient, the clarity of the situation, the attitude of leaders, confidence and communication skills, and fear of the responses of others and of appearing incompetent (Okuyama et al., 2014). Bayview's policies gave the nurse no clear permission to escalate a disagreement about a critical result, so the decision rested entirely on her personal courage at 2:20 in the morning.

Quality Improvement Tool: Health Care Failure Mode and Effect Analysis

Root cause analysis looks backward at one event. To find where the process could fail again, the team also applied Health Care Failure Mode and Effect Analysis, a five-step method developed by the Veterans Affairs National Center for Patient Safety: define the topic, assemble the team, map the process, conduct a hazard analysis and identify actions and outcome measures (DeRosier et al., 2002). The team mapped the critical result process from the moment a value is flagged to the moment treatment begins, then scored each failure mode for severity and probability on four-point scales.

Root Causes

The analysis identified three root causes. The critical result process depended on whoever answered a unit telephone, rather than routing the result to the responsible nurse. The process had no time limits or escalation path. And the hospital had no standard response to a critical potassium, so treatment depended on one physician's judgment made by phone. An analysis of more than 37,000 consecutive critical values at a large academic medical center likewise traced reporting delays to identifiable factors in the reporting process and described process changes to address them (Dighe et al., 2006).

Corrective Action Plan

The plan combines a process change with a risk management program. First, the laboratory system will send critical results directly to the assigned nurse's hospital phone, requiring electronic acknowledgment; if the nurse does not acknowledge within 10 minutes, the result goes automatically to the charge nurse, and after 20 minutes to the house supervisor. The laboratory director and the director of information systems own this change, due in 60 days.

Second, the hospitalist and pharmacy leaders will write a nurse-initiated hyperkalemia protocol, approved by the medical staff: for any potassium of 6.5 or higher, the nurse obtains an electrocardiogram, starts cardiac monitoring and notifies the physician, and approved standing orders allow immediate treatment while a repeat sample is drawn. Due in 45 days.

Third, the chief nursing officer will issue an escalation policy stating that any nurse who remains concerned after speaking with a physician about a critical result must call the rapid response team, with no penalty for doing so. All nurses and hospitalists will complete a team communication course that practices structured handoffs and speaking up, using simulation of this event. Due in 90 days.

The patient safety committee will monitor three measures monthly: the median time from critical result to acknowledgment by a licensed caregiver (target under 15 minutes), the percentage of potassium values of 6.5 or higher with an electrocardiogram within 30 minutes (target 95%) and the number of rapid response calls initiated for concerns about a critical result, which is expected to rise at first as staff use the new policy.

Conclusion

Mr. Brooks's cardiac arrest was not caused by one careless person. It was produced by a process that let a critical value wander through an unauthorized receiver, wait on a busy charge nurse and stall on a phone call, and by a culture in which a worried nurse felt unable to push back. By routing results directly to the responsible nurse, adding escalation and a standard treatment protocol and making it safe to speak up, Bayview can prevent the next delayed critical result from becoming the next sentinel event.

References

DeRosier, J., Stalhandske, E., Bagian, J. P., & Nudell, T. (2002). Using health care failure mode and effect analysis: The VA National Center for Patient Safety's prospective risk analysis system. The Joint Commission Journal on Quality Improvement, 28(5), 248-267. https://doi.org/10.1016/S1070-3241(02)28025-6

Dighe, A. S., Rao, A., Coakley, A. B., & Lewandrowski, K. B. (2006). Analysis of laboratory critical value reporting at a large academic medical center. American Journal of Clinical Pathology, 125(5), 758-764. https://doi.org/10.1309/R53X-VC2U-5CH6-TNG8

Okuyama, A., Wagner, C., & Bijnen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: A literature review. BMC Health Services Research, 14, Article 61. https://doi.org/10.1186/1472-6963-14-61