TEAMWORK IS NOT AN ABSTRACT IDEA

 

In 2010, Alameda County Medical Center was fined $75,000 by the California Department of Public Health (DPH) for a preventable medication error which resulted in a patient's death. The patient, a female with end-stage renal disease requiring thrice-weekly hemodialysis, was admitted to the hospital for sudden shortness of breath and chest pain. During a dialysis session two days after admission, she experienced seizures, hypertension, and acute pulmonary edema necessitating transfer to the ICU. At 1400, shortly before transfer to the ICU her attending physician ordered 1000 mg phenytoin IV over 1 hour (specifically mentioning that the dose should not be "pushed quickly"). According to hospital records, the order was scanned to the pharmacy 45 minutes later. Because IV phenytoin was in the ICU's Pyxis unit, the pharmacy assumed the dose had already been given and took no action on the order.

Approximately 7 hours after the order was written, the patient's ICU nurse, not having the ordered medication, called the pharmacy. According to her, she was told by the pharmacist to remove four-250 mg units of IV phenytoin from the Pyxis unit and "give it". She claimed she was given no other instructions by the pharmacist. During the investigation by the DPH, the pharmacist acknowledged receiving the call but stated that she instructed the nurse to mix the phenytoin in a 250 mL bag of saline and administer it through a 0,22 micron filter but admitted failing to provide an infusion rate. The nurse "gave it" as she believed she had been instructed by the pharmacist. Six minutes after the dose was administered, the patient arrested and was pronounced dead approximately 30 minutes after that.

While on the surface this appears to be a "she said-she said" situation, it should have NEVER come to this. Given that most reasonable pharmacists would have immediately screened such an order and construed it to be "emergent", the pharmacist should have then contacted the nursing unit to see if the dose had, in fact, been administered. If it hadn't, the pharmacist had two options. First, she could have instructed the RN to remove the medication from the Pyxis unit and then given her meticulous instructions on how to administer it. The second option, which would have been the ideal one, would have been to prepare and deliver the IV phenytoin exactly as ordered by the physician.

Teamwork requires that members of a team talk to each other, not AT each other, especially during critical times. What was most troubling in this case was that the nurse in question worked for a nursing registry and probably was not completely knowledgeable about certain policies and procedures relating to medication procurement and administration. Given that she wasn't regular staff, she probably didn't feel totally comfortable questioning what she believes she "heard" the pharmacist tell her. In fact during the DPH investigation, she was quoted as saying "...it shouldn't have happened. I shouldn't have listened to the pharmacist and it didn't sound right to give four vials IV push. I should have refused...". The pharmacist, being a regular staff member, should have taken control of the situation rather than taking a passive approach to an order she had believed had already been carried out. Was it laziness? Was it lack of proper training? Did the pharmacist see herself as a "bystander" rather than a "team member" (unfortunately, pharmacists often feel and perform like bystanders)?  None of this was revealed during the DPH investigation.  However, removing injectable phenytoin from the Pyxis unit and placing the registry nurse on a "do not return" list are, unfortunately, too little, too late.  Hopefully, BOTH departments will use this as a "teachable moment".

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