Spotlight Case

1. Spotlight Case Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer?

2. Source and Credits • This presentation is based on the May 2010AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by:Sidney W.A. Dekker, PhDLund University, Sweden • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Mary Blegen, RN, PhD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Describe the just culture approach to investigating errors in health care • Analyze system contributions to errors in care • Identify best sources of information for designing a response to an error • Distinguish accountability for failure and learning from failure

4. Case: Fatal Error in Neonate (1) An infant was born prematurely at 30 weeks weighing only 1.8 kg. He was started on total parenteral nutrition (TPN) with Premasol Amino acid solution at 3g/kg/d and Dextrose 12.5% 5mg/kg/min. After being maintained using those solutions for the first 2 days after delivery, the care team added lipids, ordered as lipid emulsion 20% at a rate of 0.19 mL/hr, on day 3.

5. Case: Fatal Error in Neonate (2) The neonatal intensive care unit, in which the infant was cared for, had frequent orders for this treatment and kept a stock of lipid emulsion on site. This practice avoided the delay between ordering, sending the order to pharmacy, and waiting for the pharmacy to dispense the new TPN solution.

6. Case: Fatal Error in Neonate (3) Within 4 hours of starting the lipid emulsion through the TPN line using a Smart Pump, the infant’s condition worsened. He showed signs of respiratory distress, pulmonary hypertension, coagulopathy, and liver failure. Soon after, the infant suffered a cardiac arrest and died. As the symptoms displayed by this premature infant suggested lipid overload, the dose and rate of administration of the lipid formulation was assessed.

7. Case: Fatal Error in Neonate (4) The assessment revealed that the pump was set to deliver 19.0 mL/hr. In the process of calculating the dose with the concentration of lipid emulsion available on the unit, the RN had erroneously set the pump to deliver 100 times the ordered dose of 0.19 mL/hr. After the error was discovered, the nurse involved was fired by the hospital and her license was revoked. The sequence of events and underlying reasons for the error were not investigated further.

8. The Present Case • The case is severe and shocking, as is the outcome: the death of a infant • In the aftermath of such an event, health care providers and organizations struggle to find the most appropriate response

9. Just Culture… • Balances accountability with learning • Determines whether outcome was result of honest error, at-risk behavior, or reckless behavior • Studies the system that allowed or facilitated the error or behavior • Improves the system for future patients See Notes for reference.

10. Is the ‘Just Culture’ Framework Helpful? • Firing the nurse and having her license revoked while ignoring the system issues surrounding the error could be seen as deeply unjust • What confidence can the family of the deceased have that another patient will not suffer a similar mishap in the future? • This case demonstrates a very narrow form of accountability and no learning—a lost opportunity

11. Determining Whether an Error Occurred • To determine whether this was an error, or at-risk or reckless behavior, one should • Involve multiple viewpoints and fairly balance them • Look at how often (and under what circumstances) this or something similar has happened, at your own facility or elsewhere • Focus on why good nurses might make mistakes like this one, not why bad nurses might do so

12. Determine System Contributions • Determine how multiple (and often conflicting) goals influenced performance: other patients, shift length, other time pressures, expectations, or procedures that could get in the way • Determine clinical knowledge of the person involved: did he or she have sufficient training for the task • What was the nurse focused on or looking at during preparation and administration?

13. A Just Culture Response • Ask the nurse what should be done • One of best starting points for Just Culture: people closest to mishap often feel responsible and eager to offer suggestions for improvement • Be sure to involve peers in any judgments of what should be done • Only way to sustain a Just Culture, in which all colleagues can feel free to report their own mistakes without fear of undue consequences

14. How Hospitals Typically Consider Errors • Pervasive belief is that safety lies in hands of caregiver, not in system that surrounds those hands • When things go well, people in health care tend to celebrate acts by people who succeeded despite the organization and its complexity • When things go wrong, we zero in on people at the “sharp end” who failed to hold that complex, pressurized patchwork together—rather than inquiring about the systemic sources behind all that complexity See Notes for references.

15. Balancing Accountability and Learning • Hospital’s response in this case is, sadly, all too typical • May have managed organization’s risk, but likely seen as unjust by all other major stakeholders: the nurse involved, her colleagues, and perhaps even patient’s family  • In the end, a hospital should balance accountability and learning • Accountability is not just holding someone responsible by meting out punishment • By sharing stories among colleagues, similar unnecessary deaths can be prevented

16. Take-Home Points • A just culture balances learning from failure with accountability for failure • In this case, the response seems unjust: only (one narrow form of) accountability, and no learning • The response, however, is all-too-typical: • Hospitals often want to manage their own (liability) risk first, with concern for their just culture coming later (if at all) • Health care generally overestimates the role of the individual actor in bringing about clinical success or failure, downplaying the contribution of the system

17. Take-Home Points (2) • Be sure to involve multiple viewpoints in determining whether an error represents an honest mistake or something worse. • Fairly balance these viewpoints, don’t just take anybody’s word for it • Accountability shouldn’t be all about meting out punishment • It can be about having people tell their stories, from which others in the hospital can learn and improve