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Difficulty: EasyPatient Safety and Quality Improvement

A 55-year-old man is admitted to the progressive care unit with a deep vein thrombosis and is receiving a continuous intravenous heparin infusion. The night shift nurse prepares to draw blood to check the patient's activated partial thromboplastin time (aPTT). While gathering supplies, the nurse is interrupted by an urgent call for assistance from an adjacent patient room. The nurse briefly leaves the supplies, returns 10 minutes later, and hurriedly draws the blood sample directly from the intravenous line through which the heparin is actively infusing. The laboratory reports a critically elevated aPTT of >150 seconds. The covering physician immediately halts the heparin infusion. However, a repeat phlebotomy performed one hour later reveals a subtherapeutic aPTT, indicating the initial sample was contaminated by the infusion line. The incident is reported in the hospital's incident reporting system. According to the principles of patient safety and quality improvement, which of the following is the most appropriate initial step in response to this event?

  1. Assemble a multidisciplinary team to investigate the systemic factors leading to the errorAnswer
  2. B
    Place a formal letter of reprimand in the involved nurse's employment file
  3. C
    Mandate that the involved nurse complete a remedial phlebotomy training course
  4. D
    Implement an immediate hospital-wide policy banning nurses from responding to emergencies in other rooms
  5. E
    Restrict the involved nurse from caring for patients receiving high-risk continuous infusions

Answer

Assemble a multidisciplinary team to investigate the systemic factors leading to the error
The correct answer is to assemble a multidisciplinary team to investigate the systemic factors leading to the error. This is a description of initiating a Root Cause Analysis (RCA). RCA is a retrospective quality improvement tool used after an adverse event or near miss to identify the underlying systemic reasons for an error. In this scenario, the nurse's error was precipitated by a sudden workflow interruption and distraction. Rather than blaming the individual, an RCA uses a multidisciplinary approach to examine systemic factors (e.g., staffing ratios, emergency response protocols, physical layout of supplies) and implements forcing functions or structural changes to prevent future occurrences.

Step-by-Step Solution

1
Identify the adverse event and the context in which it occurred.
A laboratory sample was improperly drawn from an active heparin line, leading to a temporary, inappropriate discontinuation of medication. This occurred immediately following a workflow interruption.
Understanding the context helps determine if the error was due to reckless behavior or systemic vulnerabilities.
2
Apply the core principles of systems-based practice to the scenario.
Patient safety principles dictate that errors made by well-intentioned providers are usually symptoms of systemic flaws, such as unsafe interruption protocols or inadequate staffing.
Addressing the system rather than the individual is the most effective way to prevent the same error from happening again.
3
Select the intervention that addresses systemic issues.
A Root Cause Analysis (RCA) conducted by a multidisciplinary team is the standard procedure to identify and correct these underlying systemic factors.
An RCA focuses on the 'how' and 'why' of an event without assigning individual blame.

Key Concept

Root Cause Analysis (RCA) and Systems-Based Practice
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Topics

Patient Safety and Quality Improvement

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