Cases & Commentaries

On the Other Hand

Commentary By Elizabeth A. Henneman, RN, PhD

The Case

A young woman with Takayasu's arteritis presented
to the hospital with severe abdominal pain. The patient had been
diagnosed with Takayasu's a decade earlier. The disease results in
arterial stenoses, which can cause ischemia in a variety of organs.
One of the diagnostic clues is differential blood pressure (BP) in
both arms (if there is more arteritis in one of the arm arteries
than the other), and in fact the patient had been noted in the past
to have very different BPs in her right and left arm. This had been
recorded in her chart but was not noted in her hospital room or on
her person.

The patient was admitted at 6:00 p.m. to the
intensive care unit (ICU) for monitoring, pain medication, and
intravenous (IV) hydration, in preparation for vascular surgery the
next morning. The IV, with normal saline, was started in her left
arm.

During the night shift, the midnight BP
measurement using the right arm revealed a very low pressure
(approximately 70 systolic). The nurse notified the covering
resident, giving him a concise description of the patient, her
primary admitting diagnosis, the surgery plans, and a report of the
vital signs. The resident, who had been given only a brief signout
on the patient (that did not include the history of different BPs
in the two arms), was quite worried about the hypotension and
ordered Levophed (norepinephrine), a powerful IV pressor. He did
not examine the patient—if he had, he would have found that
her mental status was normal, which might have been a clue that the
true BP was not as low as the reading. The nurse took the
resident's verbal order for the medication and administered the
drug.

When the surgical team arrived in the morning,
they were puzzled by the low BP (since the patient appeared to be
otherwise stable) and asked that the BP be reassessed, once in each
arm. When the pressure was measured in the left arm, it was noted
to be within normal range, even as the pressure in the right arm
was still very low. The team immediately discontinued the pressor
order, believing that the patient's true BP was the one from the
left arm, and that the right arm reading was due to local vascular
narrowing. Although giving a vasoconstricting medication to a
patient with narrow blood vessels could have had catastrophic
effects, no adverse outcomes were noted in this case.

The Commentary

Because of failure to identify this patient's
preexisting BP differences, she was mistakenly placed on a powerful
IV vasoactive agent, which could have led to a myocardial
infarction or a stroke. Takayasu's arteritis is a rare
disease—as a practicing critical care nurse with almost 30
years of experience, I can say I have never heard of it. The
definition of Takayasu's arteritis from the Merck Manual is "an
inflammatory disease of unknown cause that affects the aorta and
its branches."(1)
Because of its rarity, it would be easy to suggest that the errors
in this case stem from the patient having a relatively uncommon
diagnosis. But, in fact, the issues presented by this case have
little to do with the patient's medical diagnosis. Clinicians
working in ICUs are frequently responsible for the assessment and
management of patients with unusual conditions, uncertain
diagnoses, and rapidly changing hemodynamic status.

This case raises multiple patient safety
concerns. They relate to both the knowledge and experience of the
clinicians caring for the patient (human factors) and to system
failures related to accessing information, communication, and
collaborative care planning.(2,3)
While it is likely that clinician inexperience played a role in
this case, the system failures are by far the more compelling
concerns.

Inability to Access Critical
Information

A serious yet common system failure in this case
was the inability of clinicians to easily access critical
information. Data about the patient's baseline BP differences were
not available to either the nurse or resident despite having been
previously noted and recorded in her medical record. In addition,
no alerts were available to the nurse and resident about the
assessment and management of BP in a patient with Takayasu's
arteritis.

Timely access to critical information is an
important patient safety concern. The lack of technology (e.g.,
electronic medical records, clinical decision support systems) to
support bedside clinicians is a serious shortcoming of our health
care system.(4)
Emergency departments, general patient care units, and ICUs
typically use different forms and flow sheets to document findings.
Access to these records is cumbersome at best, and busy clinicians
do not have the time to search through paper records. As a result,
clinicians rely heavily on other methods of communication such as
verbal report, "cheat sheets," sign off records (index cards), and
handwritten reminder notes posted over the head of the patient's
bed. These commonly used communication mechanisms are rarely part
of the patient's permanent record, and there is frequently no set
hospital policy that governs their use.

The problem of access to critical information is
compounded by the physical limitations of the patient care
environment. Medical charts (paper and electronic) are often
inaccessible to the clinician providing care to the patient at the
bedside. Space limitations, infection control issues, and privacy
concerns often preclude access to electronic records in "real
time." The use of wireless, hands-off accessing of information and
documentation has great promise for decreasing errors related to
communicating and receiving critical data. For example, one can
envision that a patient like this might have a wirelessly
transmitted alert emanating from her room, which would
automatically alarm (or even provide a computerized voice warning
through a communication device that all nurses would carry). Like
all alerts, once the technological obstacles are overcome (wireless
communication throughout the floor, all nurses carrying the
appropriate receivers), the main challenge will be deciding which
conditions merit alerts, balancing the need to transmit information
against the ever-present risk of "alert fatigue."

The use of other innovative technologies such as
temporary tattoos has been recommended as a way of alerting
clinicians to unique patient assessment requirements. For example,
a temporary tattoo could be used during the postoperative
mastectomy period to remind professionals and technicians to avoid
the use of a particular limb for venipuncture or BP
measurement.(5) For
the patient in this case, a "do not take blood pressure in this
arm" temporary tattoo could have been applied (Figure). Sleeves that cover an arm to indicate "no
venipuncture or blood pressure measurement" have also been used.
Methods of alerting the bedside practitioner are promising, yet
they introduce new safety concerns. The use of any bedside or
applied patient alert (e.g., allergy bracelets, overhead signs,
tattoos) relies on clinicians to verify their accuracy, apply them
correctly and in a timely manner, and systematically re-verify and
update them over time. For example, wristbands are sometimes used
to alert the nurse administering medications about potential
patient allergies. These wristbands need to be applied by health
care personnel who are knowledgeable about medications and
allergies. If a patient develops an allergy later in the hospital
stay, this alert mechanism requires that someone re-enter the new
information in both the patient medical record and on the
wristband. The fact that critical information needs to be entered
in multiple places (i.e., in the medical record and on the patient)
may increase the risk of error. So, although these methods offer
hope, they should be studied before widespread implementation.

Failure to
Communicate/Collaborate

The difficulty in accessing information in this
case was compounded by a failure on the part of the nurse and
physician to engage in effective communication and collaboration
related to the patient's assessment and plan of care. The need for
accurate and timely communication is imperative to patient safety
and has been integrated into the patient safety goals of many
organizations.(6)
Although the nurse caring for the patient gave a concise
description of the patient, she failed to communicate a critical
finding, that is, the patient's mental status. The resident caring
for the patient was placed in a difficult situation because he had
received only a brief signout from his physician colleague.
Nonetheless, neither the nurse nor the resident recognized the
potential critical nature of the situation and the need for more
collaboration about assessment and care planning.

Another failure of communication/collaboration
involved the resident, attending, and other members of the surgical
team. Clearly, the resident lacked sufficient familiarity with the
patient and the diagnosis. It is disconcerting that there appeared
to be no consultation with the attending physician responsible for
the patient. It is also troubling that the surgical team appeared
to be unaware of the patient's hypotensive status when they arrived
in the morning despite the patient having been hypotensive and
receiving treatment for several hours throughout the night. From a
systems perspective, there is no evidence that any back-up was
available to the resident, and if there was, it is unclear why it
was not used.

What is also not evident from the case study is
the extent to which the patient and family were involved in the
assessment and care-planning process. Patients with chronic
conditions (and their family members) are often very knowledgeable
of their disease state and are typically aware of unique assessment
findings such as very low or very high BPs. Experts suggest that
the work environment of ICUs must be reorganized to systematically
include patients and family members if patient safety is to become
a reality.(7,8)
It is quite likely that a discussion with the patient and family
may have been all that was needed to explain the low BP in the
right arm and avert any potential for harm. Because most of the
case occurred during the nighttime, the family may have been
unavailable, but the patient was noted to be alert and may well
have offered the information if asked. It is not clear what the
visitation practices were at the hospital, but many ICUs still
restrict family visitation, so it is possible that the family
presence was restricted, adding to the communication
problem.(9)

Nurses and physicians play a pivotal role in
patient safety. Surveillance of the patient and environment,
communication, and collaboration all are necessary to prevent error
and adverse outcomes.(10-14)
This case study is not atypical. It exemplifies the many potential
problems that can occur when a lack of access to critical
information and communication/collaboration failures impact our
patients and their families.

Take-Home Points

  • Use structured communication
    forms/checklists when giving information to other caregivers to
    ensure that "critical" data are consistently relayed between
    clinicians.
  • Minimize the use of "cheat sheets" and
    other handwritten reminders that are less likely to be
    systematically included in the "hand-off" process.
  • Allow time for a comprehensive report at
    nursing change of shift and during physician "hand-offs."
  • The use of point-of-care reminders about
    key patient issues (such as through the use of temporary tattoos or
    wristband reminders) may help prevent errors but should be studied
    for acceptability, utility, and unexpected consequences.
  • Involve the patient and family in the
    care-planning and decision-making process.
  • Collaborate with fellow clinicians to
    evaluate unusual assessment findings or plans of care. Use the
    expertise of senior nurses and attending physicians.

Elizabeth A. Henneman, RN, PhD
Assistant Professor
University of Massachusetts, School of Nursing

References

1. The Merck Manual of Diagnosis and Therapy.
17th ed. West Point, PA: Merck and Co Inc; 1999:1782.

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To
Err is Human: Building a Better Health System. Washington, DC:
National Academy Press; 1999.

3. Donchin Y, Gopher D, Olin M, et al. A look
into the nature and causes of human errors in the intensive care
unit. Crit Care Med. 1995;23:294-300. [go to PubMed]

4. Committee on Quality Health Care in America,
Institute of Medicine. Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington, DC: National Academy
Press; 2001.

5. MEDtoos—Temporary tattoos to prevent
wrong-site, wrong person, wrong-procedure medical mistakes.
Available at: http://www.medtoos.com. Accessed April 30, 2007.

6. Joint Commission National Patient Safety
Goals. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals.
Accessed April 30, 2007.

7. Davidson JE, Powers K, Hedayat KM, et al.
Clinical practice guidelines for support of the family in the
patient-centered intensive care unit: American College of Critical
Care Medicine Task Force 2004–2005. Crit Care Med.
2007;35:605-622. [go to PubMed]

8. McCauley K, Irwin RS. Changing the work
environment in intensive care units to achieve patient-focused
care: the time has come. Am J Crit Care. 2006;15:541-548. [go to PubMed]

9. Kirchhoff KT, Dahl N. American Association of
Critical Care Nurses' national survey of facilities and units
providing critical care. Am J Crit Care. 2006;15:13-27. [go to PubMed]

10. Henneman EA, Gawlinski A. A "near-miss" model
for describing the nurse's role in the recovery of medical errors.
J Prof Nurs. 2004;20:196-201. [go to PubMed]

11. Henneman PL, Blank FS, Smithline HA, et al.
Voluntarily reported emergency department errors. J Patient Saf.
2005;1:126-132.

12. Henneman EA, Blank FS, Gawlinski A, Henneman
PL. Strategies used by nurses to recover medical errors in an
academic emergency department setting. Appl Nurs Res.
2006;19:70-77. [go to PubMed]

13. Rothschild JM, Landrigan CP, Cronin JW, et
al. The Critical Care Safety Study: the incidence and nature of
adverse events and serious medical errors in intensive care. Crit
Care Med. 2005;33;1694-1700. [go to PubMed]

14. Rothschild JM, Hurley AC, Landrigan CP, et
al. Recovery from medical errors: the critical care nursing safety
net. Jt Comm J Qual Patient Saf. 2006;32:63-72. [go to PubMed]

Figure

Figure. Temporary Tattoo Indicating "Do Not
Take Blood Pressure from This Arm."

Figure courtesy of MEDtoos (http://www.medtoos.com).