Commentary & Opinion
12:40 pm
Fri April 26, 2013

Andrew Coates: A Near Miss

Many years back during my residency training, on my first overnight as the senior admitting resident, I got a call from an emergency physician at a tiny rural hospital. Her patient had pulmonary emboli -- blood clots to arteries of the lungs. She proposed to transfer the patient to our hospital, where closer monitoring would be available.

When the patient arrived I hurried to the her bedside, for pulmonary emboli kill as many as 100,000 people each year in the United States. 

She asked if she might die. It occurred to me that she might. But I sought to reassure her, explaining that she was not only stabilizing but already receiving treatment.

As I gestured to the "treatment" she was getting, I looked at the bag of heparin hanging at her bedside. I was thinking that I should recheck the rate of the drip, to make sure the emergency physician had chosen the correct dose of the anticoagulant.

But there was no pump attached to the IV. In fact the bag of heparin was empty. With horror I recognized a life-threatening medical error.

A bag of intravenous heparin had been hung earlier, at the rural hospital, before the patient's transfer. The doctor who ordered the heparin meant for the contents to infuse slowly, by a pump to control the drip rate, over about 28 hours. Instead the entire bag had been infused into the patient all at once, by gravity, over a few minutes.

The ambulance crew had transported the patient with an IV pump. At the first hospital, to avoid the need to return, the ambulance crew had substituted a pump that belonged to their company. When they got to us, they simply unhooked their pump and took it with them, without taking time for our nurses to switch to a different pump.

Our patient who had just suffered blood clots to the lungs suddenly faced a profound risk of bleeding. I asked the patient not to get out of bed, to eliminate her risk of falling, and informed her nurses.

I then rushed to order the antidote, a medication called protamine. 

That we might need it some day had been drilled into us as medical students but I had never seen it used. Quickly I phoned the pharmacist for help. The pharmacist that night was just like me, recently out of school. Just like me, it was her first overnight and she too had never seen protamine used.

Awed, if not frightened, by the responsibility we shared, we independently calculated the dose of the antidote (protamine) and then took a minute to compare our results. Too much and the patient would be back at a risk of more blood clots. Too little and she would remain at a risk of bleeding. The pharmacist quickly delivered the protamine and the nurses immediately gave it. (And we notified our supervisors of the situation.)

By morning we learned that we had chosen just the right dose. The patient remained stable -- and also therapeutically anti-coagulated, without risk of further clotting. And remembering that night ... so many lessons learned!

But I'd focus for a minute on the question of the medical error as well as how thinking about it shaped my consciousness. Events like this "near miss" deserve careful review. As one of the world's experts in health care quality, Dr. Gordy Schiff points out, these experiences should be treated like treasure.  Careful study of a problem can allow us to unearth its roots, and in turn build systems that will save lives.

The ambulance crew members were good people with a sincere desire to serve the community. Of course they swore never to make the same mistake again. Yet fixing blame will not, ultimately, fix errors. When we discussed a team-building system fix the Director of Nursing pointed out that in a fundamental way, the ambulance crew was not quite part of our team.

The ambulance was run by for a for-profit company with a corporate headquarters thousands of miles away. Naturally the goal of the company was to get the crew to transport as many patients as possible across our landscape. That night, I later learned, they were racing off to another patient waiting at another rural hospital. The paramedics were amid a "speed-up" like... well, like just about everybody else in our country.

These days just about any aspect of health care delivery can be subcontracted out or made into a business. Local health care businesses are increasingly joined by the tendrils of international conglomerates. In fact the corporation that owned the rural ambulance in this essay was recently bought by a global private equity firm.

But a local ambulance crew should serve the needs of the local community, not private equity investors.

For the sake of patient safety we should work to remove profiteering from the care of the sick. A public single payer system would a giant step in the right direction. Most of all it would be the beginning of a system in which health priorities were set by the people, by patients and their caregivers, something every modern democracy should have.

Dr. Andrew Coates practices internal medicine in upstate New York. He is President of Physicians for a National Health Program.

The views expressed by commentators are solely those of the authors. They do not necessarily reflect the views of this station or its management.

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