Thursday, July 01, 2010

Is it plugged in?

Submitted by a friend of a friend. It is from a cancer patient's on-line journal. This did not take place at our hospital. It could happen almost anywhere, I'm guessing.

In our hospital, this situation would have prompted a "Trigger" because the low oxygen saturation is a Trigger standard, as is "marked nursing concern."
Would our Trigger team notice the root cause?

I thought I'd wait until I'd left the hospital to recount this story. One evening, my friend was visiting and the nursing assistant came in to take my vital signs. My level of blood oxygenation (02 saturation) was lower than normal, and so she called the nurse, who turned up the level of oxygen I was getting through my nose from 3 liters to 6 liters. It didn't seem to help. Then the Reiki lady came to give me my "sample" Reiki treatment (which I liked). Afterward, my oxygen level was no better.

The nursing shift changed and the new nurse was concerned about my "sats". She called a doctor, who couldn't see anything wrong, but was concerned, since I clearly should not have been "desatting". She gave me an EKG. She gave me another EKG. She called another doctor. She ordered a portable chest X-ray. She gave me a nebulizer treatment. This all lasts until nearly midnight.

By this time, I am getting anxious (no matter how hard I try to breathe in deeply through my nose and out through my mouth, I can't seem to get the sats up). So she is also giving me ativan. She suggests to the nurse that she call respiratory therapy and ask them to bring up a mask, so that I can breathe in through both my mouth and my nose. The respiratory therapy guy comes, but before he gives me the mask, he firmly attaches the oxygen tubing to the oxygen source on the wall. It had come loose. No one else checked.

So, I had two doctor visits, two EKGs, a chest X-ray and a nebulizer treatment because it wasn't plugged in.



Anonymous said...

From Facebook:

Beth: WOW Paul....funny but SO not!

Anonymous said...

I received this note from one of our senior attending physicians:

Desaturation is a very common trigger. I think we actually train our people to look at the gas flow to patients receiving oxygen as part of the "differential diagnosis" of desaturation.

The real concern here, though is the dithering that went on with an inadequately oxygenated patient. What we push on hardest with our folks is the necessity to determine what is causing the decompensation and to fix it. It is especially important to avoid just raising the proportion of oxygen in the inhaled gas without knowing why the patient suddenly needs more oxygen and what will prevent the patient from deteriorating further. The use of a sedative-hypnotic (ativan) in this setting, where you don't know the cause of worsening respiratory failure is also a serious error which we strive to avoid.

Anonymous said...

And yet another:

On the face of it, the story doesn't make sense, i.e., there is a difference between "no reading" (not plugged in) and a "low reading," which could be due to a poor tracing because of poor blood flow or defective probe. One would hope that a more senior person would have noted that the numbers were discrepant with the way the patient looked and the physical exam. This is one of the key messages I try to convey students and residents; if you get good enough at your physical exam, you can trust it more than a digital number (which they tend to view as absolute “truth”).

On the first day of my internship at BI, I was assigned to the ICU. The nurses brought me a rhythm strip that looked like ventricular tachycardia. I rushed to see the patient who was sitting comfortably in his bed, with a good blood pressure. The rhythm strip was due to an artifact of the nebulized vibrating up against the ECG electrode. Message: treat the patient, not the lab value.

Anonymous said...

Our chief of medicine adds:

"Dithering," a term invented by Dick Simmons (an eminent surgeon, former chair at Pitt, who became chief quality officer for UPMC while I was there when he stepped down from running the Dept of Surgery) truly drives me crazy. Any case of dithering in a trigger prompts an M and M on the subject so that we can continuously reinforce the need to get to the bottom of episodes of decompensation and make the patient safe.

Anonymous said...

From Facebook:

Vicki: It's good when people can remember to start with the simplest solution and work toward the more complicated. It's a basic life lesson that most of us can a reminder of.

Regina: Sadly, this so very common...

Lynn: Got to love Respiratory Therapists!

Michael Howell said...

Three comments:

1) We routinely teach and train that evaluating patient decompensations when on life support (which oxygen definitely is, though we don't usually think of it that way) requires evaluating the life support gizmo for potential failure -- be that a ventilator, an 'smart' infusion pump, or something as seemingly simple as oxygen. Device failure/disconnection/etc. is an uncommon but not rare cause.

2) Even with that training, respiratory support devices (oxygen tubing, masks, etc.) are complex and you sometimes need providers who are particularly skilled in the area. The case here is a great example of why we include a respiratory therapist as a routine part of our Trigger team for respiratory events.

3) It's important to remember that physical hospital design may well have contributed to the case described. Take a look at the cover of the AHRQ's poka-yoke paper ( and think about whether you would be able to notice if the oxygen tubing is disconnected. The picture there is a fairly extreme example but occurs all the time.

dlove said...

This seems like a one off type of story: way outside the norm. Unfortunately, it's not. Care delivery systems are just not designed for safety.

I find it an interesting juxtaposition between this post, and the one below it. Many of the comments that Paul is posting are of the work harder variety (we train our housestaff to THINK, dammit!). The real question is why do we have a system where something as simple and as common as an oxygen leak can endanger a patient's life? I suggest that we should think of leaky seals in oxygen delivery systems (and the like) as the faulty O-rings of this system. There's no simple solution, but "working harder" or "being more careful" are not reasonable solutions.

Alice Lee said...

I will leave the clinical lessons to be learned to my clinical colleagues while I comment more generically about the "problem solving" that took place. This is a good example of likely good intentioned folks trying to fix a problem. What is interesting is so many jumped to solutions without really understanding the actual problem and looking at the whole picture as a scientist/detective would for clues - what makes sense, what doesn't, etc. I wonder how many times in different settings, clinical or otherwise, that happens. We are trained to quickly "solve problems" but don't spend enough time on what the actual problem is. That is why problems recur...

e-Patient Dave said...

Not rare, for sure.

In my father's final months (in a Maryland nursing home), more than once we'd arrive to find the O2 cannula *beside* his nose, blowing oxygen onto his cheek.

A side note: I don't understand why insurance companies don't scrutinize their payees for fraud. If someone bills full price for a professional service and is actually not competent, I'd think the insurer would feel ripped off. I know that's not the case, so I expect our incentives are broken: the insurer simply doesn't suffer at all if a fraud is perpetrated.

An example is my own daughter's normal newborn jaundice many years ago. She was brought in to Winchester Hospital for phototherapy, and it's a good thing we stayed with her 24/7 because twice we found out (the hard way) that night nurses assigned to protect our baby had no effing idea what phototherapy was even supposed to do. (UV lights on the bare skin help the baby process the bilirubin; if the therapy is unsuccessful, permanent brain damage can result.)

One nurse said "Oh, the poor thing must be cold - I'll put a shirt on her." Another didn't understand that the isolette had to be *under* the lights, not beside them.

It's so important for patients and families to understand the treatment they're getting, to the best of their abilities, and serve as a second set of eyes.

And it's important for providers to understand that this is a legitimate thing for families to do.

Participatory medicine - an informed partnership dedicated to better care. Seriously.

Anonymous said...

A phrase I learned from a physician friend is "common things happen commonly". As someone who works in healthcare but also likes to tinker with electronics and tech stuff, I can't tell you how many devices I have "fixed" by simply connecting them or plugging them in. Its an amazing human phenomenon that we often start with the complex instead of starting with the simple and working up. Your discussion of triggers is another example of why "systems" are so important.

Anonymous said...

Potentially cascading failure caused by cognitive bias. We gravitate toward the first explanation that comes to mind, we gravitate to the one that is usually the best by force of habit, and we gravitate toward the least taxing one. I agree with the commenter above that judgment-laden critiques are unhelpful and wrong. People who don't have a notion of our inherent human foibles make me nervous! Although I hear they make pretty good surgeons...
Joking aside, very nice illustration of the role of TEAMS. This kind of thing happens all the time.

dlove said...

In my car I have a sensor that lights up when my oil pressure is low. I don't wait for my engine to heat up and then try to discern from first principles what the problem is.

If it's good enough for my Toyota, it should be good enough for my grandmother - or anyone else's for that matter.

Mommy A. said...

Sorry, I've been a lurker for awhile now, but as an RT, I had to comment. Unfortunatley this is not an uncommon occurence!

jonmcrawford said...

Dave, I don't think the problem is that insurers don't feel ripped off, it's that the service was provided was considered 'medically necessary' at the time, and unless it constitutes a demonstrable pattern of care, causes nothing more than a comment or question to the physician. Companies need to keep a good (or at least working) relationship with their physicians also, to retain their networks. Outright claims of fraud are almost never good.

However, if we assume that this patient was a Medicaid patient (which they probably weren't), the money wasted is over $100. (not using MA numbers, but in Ohio: ECG (x2)~ $40, Chest Xray ~ $20, nebulizer ~ $11, physician hospital visit (x2) ~ $36 = $107)

Assuming that Medicaid pays about 30% of billed charges (which seems to be an average), that means that this patient is being charged around 107=.3x, or $357 for a loose O2 line.

Now, since they were IP, those charges are slightly different, it's probably rolled into a DRG (case rate), etc, but still, what could be significant charges for something that could have been completely avoided.

Wonder if they still think it's funny after they get the bill?

Yet another reason to quote your last statement (bravo):
"Participatory medicine - an informed partnership dedicated to better care. Seriously."

Elaine Schattner, M.D. said...

An instructive story, for sure -

Technology can be helpful in hospitals, as elsewhere. But when we rely on it so heavily that we stop using our heads, the costs can be significant. It's kind-of like when we do simple math with calculators, or rely on GPS to take a trip. After a while we lose confidence, and practice, in how we think.

Anonymous said...


I am forwarding the case you mention to our folks for review.

Anonymous said...

From Facebook:

Matthew: Shouldn't there be a checklist that covers this kind of situation?

Everybody makes simple mistakes, smart professional people aren't exempted. I don't freak out when somebody makes a mistake in a situation like this, I freak out when there is no mechanism for learning from that mistake.

Winnie: How much did this all cost?

Benj: Happens in my world all the time . . . 98% of the technical problems we encounter are the result of very simple failures: a plug, a switch, a broken wire . . .

Anonymous said...

I think another aspect to evaluate is the likelihood of power going out for people who live at home. I am not sure if anyone on here is following the news, but a women up in New Hampshire, Kay Phaneuf, died because the energy company shut off her power. Now, I know this is not the exact same thing, but I think it begs the same basic question: the importance to make sure that a patients medical equipment, in Ms. Phaneuf's case, her Oxygen Concentrator, is hooked up and working correctly.

Anonymous said...

Brenda on Facebook:

When we teach resuscitation to those caring for newborns, one of the first things we teach is that if the baby isn't responding, check the equipment, especially the oxygen.

In this case, the patient wasn't symptomatic. I wonder if anyone asked if he was short of breath, or took into account the fact that he looked fine. I also wonder why a respiratory therapist wasn't called in much earlier.
Two lessons: always rule out a technical problem, and utilize all members of your care team.

REKording said...

I'm glad this wasn't your hospital, Paul because this is a quite serious oversight. That said, I am more concerned that a modern hospital allows REIKI therapists to visit patients with "sample therapy." Do they also allow witch doctors?

Kyla said...