DR FAIL

[VentMedic]

I agree that time-outs are very important in certain parts of the hospital. Unfortunetly, the administrators who have no pt care experience whatsoever, have decided that it is such a good thing that it should be done everywhere in the hospital, including the ER. It is a completely different environment in the OR where people are sedated and unable to speak. If I come at you with a big spinal needle to do a spinal tap, in the ER you may say, "Doc, it appreciate your concern, but really, I don't think that will help figure out if my toe is broken." If I go in the wrong room to suture someone, I will probably realize I am in the wrong room when I cannot find that gaping wound that was there 5 minutes ago. I'm pretty sure I can identify who the multi-system trauma pt is that is circling the drain and needs some help without aking everyone in the trauma bay (including said pt) if we have the correct pt. I could go on, but I think you get the point. It is the typical story of administrators seeing a good thing and taking it too far.

We do the time outs for the bigger invasive procedures such as central venous or arterial lines. Since we can run 8 ventilators (prefer not to) in the ED I have stopped residents from doing a CL on the first ventilator patient they saw because their identifier was "vent patient named Garcia". It is a good day if we only have to sort through the occasional John Smith rather than a sea of Jose Garcias, some are alias, with different languages/dialects.

For other invasive procedures, we use the JCAHO recommendations for identifiers. However, ID bands are not always reliable. If the patient is not verbal, two licensed staff members make the initial ID and the following. We still get the occasional foley, IV or arterial stick done on the wrong patient. Medication errors are of course an issue. The RN may have 6 - 10 patients as any given time. We are still working out the issues with the IDs scanners.

For all the chaos, I am surprised things flow as well as they do. But there are times someone mucks up and headlines are made.

Edited September 24, 2009 by VentMedic

[Dustdevil]

Since my only hospital experience in recent years has been in combat hospitals, I am unfamiliar with this "time out" concept. Can someone break it down for me?

We still get the occasional foley, IV or arterial stick done on the wrong patient. Medication errors are of course an issue. The RN may have 6 - 10 patients as any given time.

It happens when you least expect it. I once had a physician walk out of a patients room with chart in hand, look up at me and say, "Oh good, there you are. Give her a gram of Rocephin IM." I did. Turns out the "her" she was talking about was in another room at the end of the hall, which the physician failed to mention. Luckily, the other "her" had a diagnosis that could have conceivably used a gram of Rocephin too, so we just sort of added that order after the fact. I'd rather not have had to do that though!

[ERDoc]

Since my only hospital experience in recent years has been in combat hospitals, I am unfamiliar with this "time out" concept. Can someone break it down for me?

It happens when you least expect it. I once had a physician walk out of a patients room with chart in hand, look up at me and say, "Oh good, there you are. Give her a gram of Rocephin IM." I did. Turns out the "her" she was talking about was in another room at the end of the hall, which the physician failed to mention. Luckily, the other "her" had a diagnosis that could have conceivably used a gram of Rocephin too, so we just sort of added that order after the fact. I'd rather not have had to do that though!

A time-out is basically a procedure to ensure that the right thing is being done to the right patient. Before the procedure is started, everyone stops what they are doing and everyone has to agree on right patient, right procedure, right side. Everyone in the room has to agree, doctor, nurse, patient, tech, volunteer, janitor, wandering bipolar patient who broke out of the restraints and so on. It is becoming a JHACO requirement. It comes from the cases of people who have the wrong leg/kidney/insert body part taken off and a few other medical misadventures.

Edited September 24, 2009 by ERDoc

[Kiwiology]

... wandering bipolar patient who broke out of the restraints and so on...

you make it sound as if my presence and contribution to medical safety is unwelcome

at the risk of sounding flippant hey at the least the patient was knocked out

[VentMedic]

This was a headline on the EMS newswire recently:

http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20090916/NEWS/909160333/-1/NEWSMAP

Paramedics cited in flawed emergency call

All three paramedics were cited by the state for failing to complete a proper patient assessment, while Gonsalves was also cited for the medication error.

The various sanctions stem from an incident in early July when Mentzer responded to a report of a possible stroke patient, according to the state report.

Mentzer immediately recognized the patient was seriously ill and called the EMS dispatcher for additional assistance; Farland arrived as the patient was being loaded into the ambulance, and Gonsalves got there soon after, according to the report.

As the paramedics were working on the patient, Mentzer and Gonsalves noticed the patient's tongue was swelling, a symptom that indicated to Mentzer an anaphylactic reaction, and Gonsalves administered epinephrine, or adrenalin, through the patient's intravenous line, according to the report.

That, according to the report, was a mistake: The concentration of epinephrine Gonsalves gave the patient should have been administered through an injection under the skin, a less direct route, rather than intravenously.

Gonsalves, who admitted to giving the medication incorrectly, also told an investigator "she may not have had enough information to have even gone down that treatment pathway because she lacked a full set of vital signs or a clear history of the present illness," the report stated.

Neither Gonsalves nor Farland conducted a patient assessment, instead relying on information from Mentzer, the first paramedic at the scene, according to the report.

Additionally, there were delays in initiating care for the patient, according to the report: Airway management was not started until five minutes after Mentzer arrived at the scene, and blood pressure was first taken 10 minutes after the paramedics got to the emergency scene.

"In this case, EMT-Paramedic Farland, Gonsalves and Mentzer all failed to properly assess a patient, but rather had tunnel vision on the visual symptom of the swollen tongue," the report stated.

Acushnet EMS reported the medication error to the state within three days of its occurrence, according to Gallagher. The department's medical director, William Porcaro, also investigated the incident and worked with Gallagher to design a remediation plan that the paramedics have already completed, the report stated.

However, as the medical error system is set up in the hospitals, if the staff member discovers and admits to the error, no displinary action is taken against that person although they may have to take some additional education depending on the error.

All the "rights" must be confirmed by the person giving the medication.

This article appears to be more of a fail to assess situation.

[Kiwiology]

Eh? Do you use different concentrations of adrenaline for IM as opposed to IV over there?

We use 1:1,000 for cardiac arrest and 1:10,000 for everything else be it IM or IV.

I don't quite get that: I read into it as being "was given too much adrenaline and did the typical throw up, look and feel awful, vital signs through the the roof response"

[ERDoc]

Eh? Do you use different concentrations of adrenaline for IM as opposed to IV over there?

We use 1:1,000 for cardiac arrest and 1:10,000 for everything else be it IM or IV.

I don't quite get that: I read into it as being "was given too much adrenaline and did the typical throw up, look and feel awful, vital signs through the the roof response"

It's the whole VTach, VFib, asystole thing that worries most.

[HERBIE1]

A time-out is basically a procedure to ensure that the right thing is being done to the right patient. Before the procedure is started, everyone stops what they are doing and everyone has to agree on right patient, right procedure, right side. Everyone in the room has to agree, doctor, nurse, patient, tech, volunteer, janitor, wandering bipolar patient who broke out of the restraints and so on. It is becoming a JHACO requirement. It comes from the cases of people who have the wrong leg/kidney/insert body part taken off and a few other medical misadventures.

Thank you for explaining what a "time out" is- it's been a few years since I have worked in a hospital. I had never heard the term before, but heard of the practice. I had no idea that JHACO had made this a requirement.

Like you said though, in a busy ER setting, it doesn't always seem like it would be practical.

[Mateo_1387]

Eh? Do you use different concentrations of adrenaline for IM as opposed to IV over there?

We use 1:1,000 for cardiac arrest and 1:10,000 for everything else be it IM or IV.

I don't quite get that: I read into it as being "was given too much adrenaline and did the typical throw up, look and feel awful, vital signs through the the roof response"

Epinephrine 1:10,000 given IM seems kind of excessive. Most doses for IM Epinephrine start out around 0.3-0.5 mg, which is 3-5 mL of the 1;10,000 solution.

[VentMedic]

Thank you for explaining what a "time out" is- it's been a few years since I have worked in a hospital. I had never heard the term before, but heard of the practice. I had no idea that JHACO had made this a requirement.

Like you said though, in a busy ER setting, it doesn't always seem like it would be practical.

JCAHO and Time Out:

http://www3.aaos.org/member/safety/guidelines.cfm