Error Analysis and Recommendation

Error Analysis and Recommendation

Twenty-year-old student, Paul, developed a right-sided pneumothorax while playing soccer at 1215. He had no prior remarkable medical history. His coach transported him to the Union Hospital Emergency Department at 1225, where he was triaged immediately due to his shortness of breath at 1250 and was seen by the emergency room doctor at 1300.

Union Hospital is a 150-bed Level III trauma facility located in Cimarron View, a city of 25,000. The latest hospital safety survey indicated categories of strength (positive response) were supervisor promoting patient safety at 75% and management support for patient safety at 70%. Weak areas were staffing at a survey positive response of just 25% and a low 15% positive response for hand-offs and transitions.

Error Analysis and Recommendation

A chest film confirmed a right lower-lobe pneumothorax. The doctor ordered a thoracotomy insertion tray; as soon as the equipment was provided at the bedside, the nurse inserted the chest tube into Paul’s left side. As time was of the essence, no consent was signed and a time out, usually performed in surgery, was also not done.

Following the chest tube insertion, there was no improvement in Paul’s shortness of breath. At this time, the nurse informed the physician that the chest tube had been inserted on the wrong side. Paul was becoming increasingly agitated and the physician mentioned to Paul what had happened. The nurse noted in Paul’s record that an incident report was filed for the wrong-side insertion, following the doctor’s written order to do so.

The emergency physician attempted to have Paul admitted as an inpatient to Union Hospital so that the reinsertion could be done in the operating room. The time now was 1345. The nursing supervisor informed the physician that there were no available inpatient beds at Union and Paul would need to be transported and admitted to Jefferson Memorial, five minutes away.

As an ambulance was on standby at Union, the emergency physician ordered immediate transport and also communicated with the surgeon at Jefferson about Paul’s condition. The unit secretary had just returned from taking a late lunch break and did not see the transfer order. The nurse was admitting another patient to the emergency department. The emergency physician, after writing Paul’s transfer orders, was now dealing with a serious motor vehicle injury patient.

Paul oxygenation status continued to decompensate and he lost consciousness. At 1430, the secretary noticed the order and clarified with the nurse. When the nurse went to reassess Paul, he had expired. The physician has professional liability insurance as a condition of his employment at Union. The nurse does not.