A Death in Denver: Anatomy of a Sentinel Event

1. A Death in Denver:Anatomy of a Sentinel Event

3. Synopsis of the Event An 8 year old boy admitted for elective surgery on the eardrum He was anesthetized and endotracheal tube inserted, along with internal stethoscope and temperature probe Anesthetist did not listen to chest after inserting ET. Temperature probe connector was not compatible with monitor (hospital had changed brands the previous day). He asked for another but did not connect it

4. Synopsis - continued Anesthetist also did not connect stethoscope Surgery began at 0820 and CO2 levels began to rise after about 30 min Anesthetist stopped entering CO2 and pulse on chart Nurses observed anesthetist nodding in chair, head bobbing Nurses did not speak to anesthetist because they �were afraid of a confrontation.�

5. Synopsis - continued At 1015 surgeon heard gurgling sound and realized that airway tube was disconnected. Problem was called out to anesthetist who reconnected it Anesthetist did not check breathing sounds with stethoscope

6. Synopsis - continued At 1030 patient was breathing so rapidly the surgeon could not operate � notified anesthetist that rate was 60/min Anesthetist did nothing after being alerted At 1045 monitor showed irregular heartbeats

7. Synopsis - continued Just before 1100 anesthetist noted extreme heartbeat irregularity and asked surgeon to cease operation. Patient given dose of Xylocaine, but condition worsened At 1102 patient�s heart stopped beating. Anesthetist called for code, summoning emergency team ET tube was removed and found to be 50% obstructed by mucous plug

8. Synopsis - continued New ET inserted and patient was ventilated Emergency team anesthetist noticed that airway heater had caused the breathing circuit�s plastic tubing to melt & turned it off Patient temperature was 108F Patient died despite efforts of code team

9. Results of the Investigation The anesthetist was found not to have hooked up the temperature probe before the surgery Hospital change in brand of probe There had a prior reports (by the chief of anesthesia) that the anesthetist Had been seen sleeping 6 times in theatre during surgery Was verbally abusive of nurses Had a drug and alcohol problem

10. Synopsis - continued The anesthetist had been seen by the physician assistance arm of the Board of Medical Examiners diagnosed as having an antisocial personality disorder

22. Summary of Sequential Errors Anesthetist 1. Procedural - failure to auscultate after initial ET insertion 2. Decision � Initiated anesthesia without temperature monitor 3. Decision -failure to connect internal stethoscope Nurse 4. Decision - failure to awaken anesthetist Anesthetist 5. Procedural - failure to maintain alertness, monitor patient and notice ET disconnection 6. Procedural - failure to confirm ET placement after reconnection 7. Decision - failure to act promptly on elevated respiratory rate 8. Decision - failure to maintain anesthetic record Surgeon 9. Decision - failure to act on inadequate response from anesthetist

24. What Should have been done before the sentinel event? Peers? Nurses? Hospital? Medical association?

25. The University of Texas Human Factors Research Project www.psy.utexas.edu/HumanFactors