After a root cause is identified, the team constructs a cause and effect (fishbone diagram) to better understand the problems that led to the adverse event.

CASE

91 yo M w/heart failure admitted to General Hospital med/surg unit w/Acute Kidney injury

Consults: Heart Failure service, Renal Service

Dx: Heart failure exacerbation

Rx: diuretic drip (bumetanide) w/limited diuretic response, renal function worsening Decompensates on unit. Decision made that the pt needs transfer to CCU for acute cardiogenic shock including inotrope therapy Delay in transfer and initiation of inotrope therapy PEA arrest upon arrival to CCU - death.

Timeline :

7/26 - 2000 - Admit from ED

8/1- 1530 - BP 83/50;Recheck by MD 100/55, no intervention

8/2 - 0525- BP 81/50; MD not notified

700- Rapid Response for AMS w/ BP 80s/50s; bumetanide dc'd, given IVF

0745 - 70s/40s; Plan for ccu transfer

0825 Dobutamine and CCU transfer orders placed by MD. Unable to start meds on floor

0850- Arrives in CCU ; BP 74/43.

0927- Patient expired due to PEA arrest

To summarize: there is a delay response for hypotension. A RRT (Rapid Response Team) is called to send a team of health care providers including an ICU nurse to the patient with early signs of deterioration in non-intensive care units.

Additional Details:

• Nurse was same as day prior - coming off a 16-hour shift.
• Did not notify team of BP because similar value the day before did not change the management
• CHF noted from prior days: "Please contact inpatient cardiology consults team for any questions/concerns that arise"
• Nurse asked resident "Would you like to call second RRT to bring MICU nurse to floor who can start dobutamine drip?" Resident replied: "let me check with my team"

Three issues that were identified as "going wrong" :

1. Delay in MD awareness of hypotension
2. Starting dobutamine on floor
3. Process of transfer to ICU level of care

Cardiology Perspectives

CCU Nurse: Accepting CCU Nurse: Plan for CCU transfer (getting room ready with IV fluid hook ups etc) is put into motion once she receives notification directly from the attending

Cardiology Fellow: Current fellow (not involved in the case) is not entirely sure of all the details regarding the process for transfer to CCU - process is not clear to the fellows; Only on service 1 week and are constantly rotating

Cardiology Services: Cardiology Services must be aware of ALL admissions coming to Cardiology service (whether floor or CCU); The issues in this case regarding bed availability.

Only the Cardiology attending knows which beds are truly available and can give authority to allow admission or transfer to CCU; For admissions/transfers to floor, Cards Fellow can triage these pts and make that judgment. However, admissions to CCU require attending to be aware; For urgent issues, the Cardiology consult pager is not appropriate (they are in the clinic 1.5 days out of the week).

1. Was this an error, near miss, or adverse event?

2. Make a fishbone diagram - Use as spine titles- People, Environment, Communication, Training/Experience, Policies/Processes, Information Systems

3. Based on your identifying the root causes of the issue, what are some of the actions might you suggest? (Note the hierarchy of actions - you should have a mix of actions)

4. Go back to the interventions you suggested in question 3 and label one from the following impact/effort matrix

High Impact/Low Effort (HI/LE) - are the best interventions. You make little effort but make a big difference. These are quick fixes. Not every problem will have a solution in this category (ex: changing standard orders)

High Impact/High Effort (HI/HE) - tend to be large scale projects which require a lot of effort and resources but usually work (example: purchasing expensive new technology)

Low Impact/Low Effort (LI/LE)- these don't make much difference. Sometimes these interventions are important in the long term. (example: writing a policy might be low effort, but it won't have influence on its own)

Low Impact/High Effort (LI/HE) - these solutions should be avoided. Unfortunately, many interventions suggested by organizations fall into this category because the impact is thought to be much greater. (example: Administration suggesting expensive new technology but front-line staff know it won't make much difference. Education might also fall into this category. Educating staff takes a lot of energy and resources but may not have a consistent impact).