Overdose of Morphine - Case Study Example

Childrens Case Analysis CHILDRENS CASE ANALYSIS Introduction Medication errors account for a number of adverse reactions and fatalities which mar the generally accepted traits associated with the medical profession and shatter the inherent trust patients have for the experts attending to their ailment. Error-free practice is constantly reiterated in key healthcare professionals-physicians, nurses, and pharmacists. However, when mistakes do occur, these key healthcare professionals have to handle shame, guilt as well as personal responsibility for such inevitable errors. Although the nearest error leading to an accident is usually a human one, the causes of that error often are beyond the individual’s control. That is, systems that rely on perfect performance by individuals to prevent errors are doomed to fail. Healthcare persons typically react to a specific accident by focusing on the error rather than attempting to understand the systematic cause and designing interventions that minimize if not altogether eliminate the occurrence of such errors. Medication errors are the most common preventable cause of adverse events. Early detection and constant reporting of such errors is crucial, particularly in hospitals, where systems for detecting adverse drug reactions and medication errors can save lives, money, and legal problems. A well kept log for such errors enables the experts to design strategies for their prevention, which is usually the better option, rather than a post scenario cure. Administrative, organizational, educative reforms as well as software controlled electronic systems can be designed after the evaluation of logs of such errors, which can prevent their occurrence in future. The medical literature today is rich enough and easily accessible for a medical professional in any capacity, to update their knowledge and look for preventive solutions in case of any doubt while administering their art. A proper coordination of medical staff and availability of ready consultation at the time of need can go a long way in preventing medical errors and accidents. The Incident The incident of an overdose of morphine in case of a ten-year old boy named Matthew at Children’s Hospital in Minneapolis illustrates a system error, which could have resulted in fatal consequences if it had not been addressed and handled in a practical manner reflecting evidence-based practice. The case described a pediatric patient of stable condition who has been transferred from the intensive care unit to the medical/surgical unit with an order for a continuous morphine drip. Upon set-up of the drip a miscalculation in dosage secondary to incorrect label occurred resulting in an adverse reaction of respiratory arrest for the patient. New graduate nurse, O’Reilly observed deteriorating condition of the patient secondary to administered morphine and promptly sought help. Proper antidote was given, allowing for the patient’s full recovery. After the overdose incident the hospital administrators were presented with a challenge to understand the sequence of events that lead to the overdose. Careful analysis of the event without the practice of blaming anybody was already practiced at this facility and revealed the exact cause of the medication failure. The importance and difficulty of communicating such news to the affected family were realized and this forced the think tank at the hospital to reevaluate and restructure their strategy for prevention of such incidents in the future. The hospital already had a well enlightened and experienced expert in hospital safety at the reigns as a Chief Operating Officer who was redesignated and put in charge of a program to devise and initiate a hospital safety program in coordination with team leaders from pertinent specialties. Recommended Course of Action If we take the above particular case, in hindsight we can suggest a number of solutions and measures to prevent such incidents in future. These can include: 1. The use of smart pumps for preventing medication errors. A smart pump is an infusion device with an embedded computer. The computer is equipped with safety software known as “dose error reduction system” which contains drug libraries that consist of specific concentrations, dosing units and predetermined dose limits. Disadvantage of the smart pump is that it allows the user to bypass the safety features by allowing the pump to function as a general purpose infusion pump, in this generic mode the pump functions to deliver fluids based on volume over time. As a result, it is important to create a culture of competence and safety among users of the smart pump to prevent bypassing of the safety features that the pump is designed to prevent. 2. Institute a multidisciplinary approach in medication verification. A multidisciplinary approach can be employed where the brand name of the medication, the dosage form and the mode of administration are explicitly indicated in permanent records which are accessible at all locations where the patient is intended to be shifted and all attending medical personnel transfer and familiarize with the patient’s record comprehensively between each other. A three tier verification process by either the staff on duty or an online specialist within the hospital network can eliminate such instances. 3. Increase awareness to staff concerning medication errors. Increasing awareness to staff concerning medication errors can be accomplished by informing staff of errors as they occur or are reported in the literature. Awareness can be raised by providing a bulletin board in the medication administration room that posts reminders of errors and tips on making the process safer. Personal counseling regarding medication errors can raise personal awareness one person at a time. The goal of increased awareness is to thwart the occurrence of similar errors. 4. Availability of Equipment Instructions & Literature within its vicinity. Salient points of using the electronic equipment which are pertinent to dosage delivery should be written down on conspicuous information sheets which can be posted on the bulletin boards or the area where such an instrument is located. Manual calculations should be verified electronically. 5. Effective Placement of Supervisory Staff in such Locations. Experienced and well trained supervisory staff should be available at the beck and call of nursing care providers for consultation, if necessary, in areas where critical care patients are housed. 6. Quality Control and Maintenance. Wherever automated dosage systems are used, the equipment should be regularly inspected and checked for maintenance at the recommended intervals. Appropriate mechanisms should be in-built to prevent software corruption and chances for error in the equipment should be nil. 7. Replacement of Staff at recommended Intervals. Fatigue and overwork are the primary factors which can lead to human error in such locations. Fresh staff should be replenished at the recommended intervals according to the hospital manual and prescribed hour of work. All these measures could have eliminated the chances of maldosage at the very outset. But such measures cannot be taken as a foolproof solution as it is not practicable to create such ideal situations in real life settings. As far as the calculation of the right dosage is concerned, mathematical errors are common even for the best experts in the subject, let alone a freshly trained nursing staff. Such mistakes of calculation are common for humans and therefore must be carried out using a calculator or a computer. Software programs can be developed which deliver the dosage calculations based upon inputs of differently branded names of the same drug. Pros and Cons According to the above recommendations, instances of wrong medication can be avoided if any of the described method is employed. Only the recommended and standard operating procedure for the smart pump should be employed and switching it to manual mode should be totally prohibited. If manual operation becomes necessary on certain occasions, it should be handled by a multi disciplinary team in consultation with each other. A multidisciplinary approach, if employed can eliminate such errors as more persons are likely to notice an error prior to the actual procedure being carried out. Availability of precise, shareable information about the medication between the attending staff and use of written records before actually undertaking a medication procedure can reduce such errors. Regular awareness programs and refresher educational endeavors can enable the staff to realize and rethink about the latest safety measures and incorporate them in their daily duty. Availability of salient protocols of the equipment to be used within the vicinity of the equipment is essential for ready reference in case of any doubt for the attending staff. Supervisory staff in areas of high operative intensity where freshly trained graduates might be practicing is essential for seeking proper guidance while carrying out therapeutic interventions. Strict quality control and maintenance of equipment is also essential for flawless operation. Replacement of staff at the recommended interval is absolutely essential in order to prevent errors due to fatigue. Questions & Answers 1. What is your assessment of the Patient Safety Initiative at Children’s? The Children’s Hospital and Clinics is a vast organization as is evident from its history. Since its formation in 1994 in Minneapolis, it boasts of 270 staffed beds, 3.455 employees and 1,500 physicians which seem to be a well balanced figure for an institution of this proportion. As it caters mainly to the children - administering primary healthcare to advanced medical procedures, it has a fair amount of responsibility to identify and address patient safety issues within the organization. The Patient Safety Initiative undertaken by the administration under the guidance of the well experienced Julie Morath who has been the Chief Operating Officer (COO) since 1999, and has attended executive sessions at Harvard University on medical errors and patient safety is therefore the most appropriate choice. Her identification of patient safety as breakdowns of complex systems existing within the hospitals and not simply mistakes of any individual itself shows the competence she possesses in addressing the issue. Prioritizing safety as the topmost concern within the organizational setup of the hospital at a corporate level may seem a Herculean task but it aims to address the issue by the scruff of its neck. Morath’s efforts to bring safety issues to align within the whole organizational setup rather than being confined to just the frontline people who handled the patients is a revolutionary idea. Morath set about initiating the safety awareness by enlightening the hospital staff at all levels about the research findings at the national level about patient safety. Her next measure was identifying focus groups and training them for safety issues within the Children’s Hospital and Clinics. On the basis of these initial endeavors she launched the detailed strategic plan for the Patient Safety Initiative. Within a short span of two years Morath was able to put into place the strategic initiative and bring about organizational change with the approval of the Board of Directors which ensured the setup of a medication administration system with zero medication defects. At the very outset, she coined the acronym SAFE (Safety, Access, Financial and Experience) as the vital components of her strategy for initiating the safety program at the hospital. This set the ball rolling in the right direction for the implementation of Morath’s envisaged safety agenda. The beauty of the program was the total commitment and involvement she elicited from both work process and management system levels. The plan to disclose medical information to families was yet another bold step which was aimed at addressing the ethical issues concerned with patient safety. The actual application of the Patient Safety Initiative was the timeliest administrative decision made in the history of the Children’s Hospital as the statistical evidence thereafter shows improvement and tremendous progress in the hospital safety record. Concern for safety was shared by every staff member with equal aplomb eliminating hierarchies in a blameless environment. Appropriate regulatory teams to identify focus areas such as the Patient Safety Steering Committee (PSSC) were formed to ensure the proper implementation of the safety protocols to be followed at the hospital. The right professionals were put at the helm of affairs, who addressed and regulated the recommendations and identified safety issues gathered from the good catch logs available for private and anonymous inputs obtained from safety issues and concerns encountered by the attending nursing and other medical staff. 2. What do you think about blameless reporting? Blameless reporting was one of most innovative measures employed in the Patient Safety Initiative. Changing the vocabulary of vital concerns associated with patient safety such as ‘study’ instead of ‘investigation’, ‘accidents’ instead of ‘errors and ‘systems’ failures instead of ‘people’ failures was the first positive step in this direction. This encouraged the frontline reporters of medical accidents to report honestly without the fear of being reprimanded or punished. This lead to the identification of the underlying causes for medical accidents which could then be addressed effectively and strategies developed to prevent their recurrence. The medical accidents, if they did occur, were considered as system failures rather than individual mistakes and accountability was not thrust upon the involved individual or department but the core issue addressed for future non occurrence. 3. What barriers did Chief Operating Officer (COO) Morath face as she tried to encourage people to discuss medical errors more openly? How did she overcome those barriers? Initially, the affected staff at the hospital was reluctant to even recognize that there were significant errors at the hospital facility when the overall national data of medical errors was shown to them. However upon self reflection, most of the staff was able to identify and understand the gravity of such errors within the hospital setting. Morath inculcated a new school of thought within their minds about looking at such errors with an entirely new perspective. Such errors were recognized as the general trend in all healthcare facilities which needed to be addressed effectively. Morath’s idea of conducting confidential focus groups under the guidance of a market researcher was a huge success and people from different areas of the organization became more aware about the safety concerns of the patients. 4. What is your assessment of Morath’s leadership of the organizational change process at Children’s? Consider the challenges she faced at each stage of the transformation process and evaluate her effectiveness in addressing these challenges. Describe in detail, why or why not? Julie Morath’s vast experience and her genuine concern for patient safety and dissatisfaction at being a mere COO propelled her to accomplish the implementation of the Patient Safety Program at the Children’s Hospital in Minnesota. Her approach was methodical and she selected the right people for the job in a stepwise approach to revolutionize the way patient safety was viewed at the facility. The enormity of the organization and its multifarious facilities did not overwhelm her and were harnessed and put into a single entity with the concern for patient safety enveloping all those involved. Her leadership qualities were impeccable as she overcame the initial hurdles of reluctance to admit the existence of such errors by the concerned staff. She constituted the right committees to address pertinent issues and put experts at the helm of affairs. Total commitment from the frontline staff was elicited by preparing focus groups to enlighten them about the safety concerns and involving them to share their incidents in a blameless environment. She used the core components of research and education to strengthen the safety program. She initiated and got a new plan for patient safety and goals approved by the board of management which encouraged learning from errors at the front line as well as at management system levels. The constitution of the PSSC was a key event which led to the development of a revised safety reporting system. Focused event analysis became the benchmark for identifying accidents which enabled the development of future strategies to prevent their recurrence. The formation of Safety Action Teams at the clinical units within the organization was the final step which ensured the application of the identified safety norms at the root level. The major challenge faced by Morath was the plan to disclose the information about medical accidents to the parents which was initially resisted by other experts within the organization. Morath’s efforts resulted in the implementation of a more realistic and honest attitude in revealing such details to parents which sought to minimize the blame on a particular individual and addressing the issue in a more shareable and effective manner which was successful in inculcating confidence in parents. 5. What would recommend that Morath should do and say in the meeting with the patient’s parents? -- Write about concepts of disclosure, necessary elements. Please include concepts of empathy as one of the elements. The right way as envisaged by Morath herself would be to enlighten the parent’s in a candid manner about the true facts of a situation in which a medical accident has occurred and convince them about the unavoidability of such occurrences within an organizational setup despite the implementation of foolproof safety protocols. She should empathize along with the concerned staff and enlighten the parents about the safety protocols being used at the facility for such accidents. Grief should be shared on a common platform and an open attitude rather than a secretive one should be used. As certain accidents are possible in critical care patients, it should not be the reason for undermining the preciousness of an individual’s life. 6. In the last section of your paper, reflect on a time during your career (if applicable) when you were empowered to speak up at work, Then, think of a time when you felt uncomfortable expressing your views, asking questions, etc. What factors contributed to the atmosphere of openness? What aspects of the work environment discouraged you from speaking up? (Note: If you do not have work experience to contribute here, consider how you might react in similar situations.) In a similar situation, I would tend to be honest and admit the error or accident and seek to redress it in the most appropriate manner. I would consult the appropriate expert and seek ways to offset the repercussions of the error in an appropriate manner as was done by O’Reilly. A working atmosphere where one another’s views and values are respected without any implication of authority or a punitive measure later on would discourage honest admissions in such situations. The blameless atmosphere as envisioned designed and put into practice by Morath serves as an encouraging factor in such situations. In hospitals with hierarchical setups, where the top bosses enforce their dictum, such openness would be impossible as it usually instills fear in the minds of the junior staff. This allows for the inculcation of a tortoise mentality which makes lower staff shirk from admitting mistakes. Positive atmospheres where educational endeavors and research updates keep everybody abreast of the latest safety protocols to be followed in a cohesive and cooperative manner ensure the success of such programs. Conclusion The document explains the need for the implementation of a patient safety program at any hospital or healthcare facility and shows how it was initiated and implemented at one of the premier large institutions, the Children’s Hospital and Clinics at Minneapolis, Minnesota. The person at the helm of affairs Julie Morath was instrumental in the successful implementation of a revolutionary program which aimed to address concerns of patient safety in young children by involving the whole staff in a team effort. She began the program in a methodical manner by identifying the core issues and developing strategies in close cooperation with experts from various fields as well as the staff at the hospital. Financial, executive, operational and organizational goals were set and met with remarkable success leading to a path and direction for further progress. Edmondson A., Roberto M.A. & Tucker A., (2007). Childrens Hospital and Clinics (A), Harvard Business School, 1-25 Read More