Partnering with Families and Patient Advocates: Another Line of Defense in Adverse Event Surveillance
In the July 16, 2019, issue of Pharmacy Practice News, ISMP president, Michael R. Cohen, published a noteworthy commentary about what healthcare consumers can do to help prevent medication errors.1 The inspiration for the commentary arose from significant dialog and questions received in response to articles ISMP published in this newsletter in early 2019.2-5 These articles were about a fatal error in which a woman received the paralyzing agent vecuronium, retrieved from an automated dispensing cabinet (ADC), instead of the sedative VERSED (discontinued brand of midazolam) (see Sidebar).
In sharing the story of this terrible tragedy, we attempted to extract all the lessons learned about the risks associated with using neuromuscular blocking agents and ADCs, and contemplate the importance of a Just Culture of safety in healthcare. One thought-provoking question stood out and was recently asked not by a healthcare provider but by a long-time consumer advocate focused on improving patient outcomes, Ilene Corina, president and founder of the Pulse Center for Patient Safety Education and Advocacy: “Is there anything that healthcare consumers themselves could have done to prevent or detect this event that might have improved the patient outcome?” The answer to that question formed the basis of the Pharmacy Practice News commentary, which is summarized in the description that follows.
Our initial response to the question was “No,” as we could not think of anything that a consumer could have done to prevent this tragedy. But the consumer advocate clearly had been thinking about this event and delved a little deeper, asking: “What if the patient had been encouraged to have a relative or patient advocate go along with her to radiology to sit with her while waiting for the radioactive tracer to perfuse?” The idea gave us pause as we thought about the numerous events that had been reported to ISMP in which a family member or patient advocate had noticed something unusual about their loved one and brought it to the attention of healthcare providers, thus avoiding a potentially catastrophic outcome.
What harm would it cause to allow, even encourage, a family member or consumer advocate to accompany a patient to a diagnostic area to wait with them prior to a test? In this case, the patient was observed via a camera that was not sensitive enough to identify that the patient’s chest was not rising and falling after receiving the neuromuscular blocking agent in error. But a family member or advocate, sitting with the patient, could have recognized that the patient had stopped breathing and alerted radiology staff to the emergency. We had to agree that the presence of a family member or patient advocate might have saved this patient’s life.
Engaging the Family and Patient Advocates in Safety
Studies have shown that family members can help detect harmful or potentially harmful critical events before injuries occur, or mitigate the duration and severity of harm, particularly when family members spend time with patients observing their care.6-11 While hospitalized patients may be too young, ill, or confused to meaningfully participate in their own care, family members are often keen observers who are highly motivated to ensure that the right treatments are correctly provided to their loved ones.8-11
The types of critical events detected by family members or patient advocates are diverse, though respiratory distress, medication errors, and tubes or drains that become disconnected are the most commonly reported safety problems.6-11 In many cases, the events were intercepted before an injury occurred. Examples of events detected and reported by family members include:6-11
Missed medication doses
Wrong drug, wrong time, wrong route, and wrong patient medication errors
Known allergies to prescribed medications or diagnostic contrast dyes
Inadequate monitoring post procedure or following drug administration
Wrong weights listed on medical records used for prescribing medications
Intravenous (IV) lines disconnected at the patient access port
Swollen, painful arms when IV infusions became infiltrated
Abscess at IV catheter site complicated by deep vein thrombosis
Respiratory distress, respiratory failure, or unusual respiratory sounds
Symptoms of significant hypoglycemia and hypotension
Diarrhea and hemorrhoidal bleeding that required transfusion
Cords or swaddling blanket wrapped around an infant’s neck, causing strangulation
Patient advocacy begins by including the family or advocate in the patient’s care and keeping them well informed so they know what to expect and can recognize if something is not right. Family members and patient advocates should be encouraged to speak up about any concerns or worries. They know the patient better than anyone on the medical team, so communication of their observations is extremely important. When family members and patient advocates do speak up, healthcare professionals should take the time to actually hear and understand their concerns and then take action in a manner that fosters true collaboration and empowerment. In fact, some hospitals have recognized the important role family members and patient advocates can play in detecting untoward events in their loved ones by allowing the family and advocates to call a rapid response team if they suspect something is not right.12 Some even invite them to participate in medical rounds.
Certainly, the presence of family members and patient advocates during a loved one’s hospitalization is not possible in all circumstances, but perhaps more could be done to encourage family members and/or patient advocates to remain with patients and to accompany them to diagnostic areas or other clinical areas of the hospital where patients might await interaction with a healthcare professional. This is an idea worth exploring, not only for patients visiting radiology but throughout a hospital encounter. Engaging family members and patient advocates as partners in identifying otherwise unrecognized errors and adverse events is a potentially promising approach for enhancing safety surveillance.
- Cohen MR. Can health care consumers help prevent med errors? Pharmacy Practice News. July 16, 2019.
- ISMP. Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. ISMP Medication Safety Alert! 2019;24(1):1-6.
- ISMP. Another round of the blame game: a paralyzing criminal indictment that recklessly “overrides” just culture. ISMP Medication Safety Alert! 2019;24(3):1-5.
- ISMP. Sidebar 1: system vulnerabilities that contributed to the error. ISMP Medication Safety Alert! 2019;24(3):2.
- ISMP. Don’t miss a persuasive article by David Marx—reckless homicide at Vanderbilt? A just culture analysis. ISMP Medication Safety Alert! 2019;24(5):2-3.
- Frey B, Ersch J, Bernet V, Baenziger O, Enderli L, Doell C. Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit. Qual Saf Health Care. 2009;18(6):446-9.
- Hurst I. Vigilant watching over: mothers’ actions to safeguard their premature babies in the newborn intensive care nursery. J Perinat Neonatal Nurs. 2001;15(3):39-57.
- Weingart SN, Pagovich O, Sands DZ, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med. 2005;20(9):830-6.
- Daniels JP, Hunc K, Cochrane DD, et al. Identification by families of pediatric adverse events and near misses overlooked by health care providers. CMAJ. 2012;184(1):29-34.
- Khan A, Furtak SL, Melvin P, Rogers JE, Schuster MA, Landrigan CP. Parent-reported errors and adverse events in hospitalized children. JAMA Pediatr. 2016;170(4):e154608.
- Khan A, Coffey M, Litterer KP, et al. Families as partners in hospital error and adverse event surveillance. JAMA Pediatr. 2017;171(4):372-81.
- Wang SS. Teaming up to prevent ‘crashes.’ The Washington Post. September 4, 2007.
Six steps to tragedy: The error revisited
A woman was admitted to the hospital with a hematoma of the brain, possibly related to a mass. Several days later, she was transported from a step-down unit to radiology for a full body positron emission tomography (PET) scan.
After a radiology technician had explained the PET scan, the patient requested medication to help ease anxiety due to claustrophobia. This led to an order for Versed (midazolam), and a nurse from the step-down unit was called to come to radiology to administer the drug to the patient.
To obtain “Versed” from the automated dispensing cabinet (ADC), the nurse typed just the first 2 letter characters of the drug name, “VE,” into the search field but did not find the drug under that name, notably because the cabinet was set to retrieve drugs by the generic name—midazolam in this case.
The nurse set the ADC to override and again typed “VE” into the search field, this time retrieving vecuronium instead of what she thought was Versed.
The nurse traveled to the radiology department and prepared the drug as per instructions on the vial label. Not realizing she was administering a paralyzing agent to the patient instead of Versed, the nurse injected the vecuronium intravenously.
The unventilated patient was then left in a holding room under camera surveillance while awaiting perfusion of a radioactive tracer that had been injected in preparation for the scan. The patient stopped breathing and was unable to call for help.
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