Cases and clinical stories have always been used in medical schools and clinical practice as a means of education and reflection on the nature of disease. The presentation of a case of diabetes, for instance, will illuminate understanding of the evolution of the disease, potential complications, and impact on the patient and their family. Cases can also be used to illustrate the process of clinical decision-making, the weighing of treatment options and sometimes, particularly when errors are discussed, the personal impact of incidents and mishaps. Incident analysis, for the purposes of improving the safety of healthcare, may encompass all of these perspectives but critically also includes reflection on the broader healthcare system.
We now take the concepts described above and apply them to clinical practice to show how chains of errors can combine to cause harm to patients. We also examine the role of the wider organisation by considering the various factors that contribute to the likelihood of an error and harm to a patient. We consider two illustrative cases of common presentations in acute hospital settings. The first evolved over several days and the second over a much shorter time frame (hours). In each case, we see a chain of errors and other problems in the process of care which combine to cause harm to the patient. We also, importantly, see how working conditions and wider organisational issues impact on clinical work and how vulnerabilities in the healthcare system pose major risks to patients.
Box 3.1: An Avoidable Patient Fall
An 88-year-old man was brought to the emergency department (ED) in the early afternoon by his wife and daughter. He had been becoming increasingly confused at home and was not taking care of himself as he normally would. His past medical history included chronic obstructive pulmonary disease, aortic valve replacement for stenosis, a laminectomy for sciatic nerve decompression, and benign prostatic hypertrophy. His presenting complaint was worsening confusion and hallucinations, disturbed sleep, poor appetite, and increased shortness of breath.
He was clerked in by a trainee doctor at 16:20 and seen by a consultant physician at 17:15 when a provisional diagnosis of sepsis of unknown origin was made. A bed was found on a medical ward (MW) and was transferred from ED at 21:00.
A falls risk assessment was undertaken in ED and he was found to be at high risk, unfortunately no falls action plan was made and the level of risk was not adequately handed over to the staff on MW. The family spoke to members of staff in ED and on MW about their concerns that the patient may fall and injure himself particularly as the bed on MW was in a bay at the end of the ward where the patient would not be easy to observe.
The ward was busy and it was staffed to agreed levels but the dependency of the patients was high. The nurse looking after this patient decided that he was settled and did not need 1:1 care but asked the care support worker (CSW) to review him regularly. The patient was being cared for on a bed with side rails (not recommended in high risk patients as they can become entangled in the rails if they are confused) and not on a low level bed with “crash mattresses” either side as recommended for patients at risk of falling.
At approximately 21:45 the patient was found on the floor by the bed having fallen. He was confused and complaining of pain in the right hip and thigh. He was reviewed by the trainee doctor on call whose note read (sic)
Asked to see patient as unwitnessed fall, found by nursing staff alert but very confused, admitted with confusion and urinary tract infection. Plan for ECG, review of right hip in the morning for development of swelling/bruising, close observation to prevent further falls, day team to consider if further imaging is required.
The patient was moved to a bay where he could be closely observed, the ECG was reviewed (nothing acute was seen) and the nursing notes recorded an otherwise uneventful night with no obvious pain.
The morning ward round was conducted by a different trainee doctor and the speech and language therapists came to review the patient and decided that he was too drowsy and confused to take fluid safely by mouth and so the intravenous infusion should continue. The trainee doctor decided that an X-Ray of the right hip should be done but requested it as a routine investigation and it was not, therefore, prioritised. The handover to the trainee doctor on call that night mentioned that the X-Ray had not been done and that it needed ‘chasing’.
A different trainee doctor undertook the ward round and notes concerns were raised in the nursing notes about bruising around the right knee but the patient also had a low blood pressure requiring closer monitoring and a fluid challenge. By 13:15, the X-ray had still not been done and the trainee doctor called the radiology department. At 16:00, the trainee doctor was called by the radiologist to report a hip fracture and suggest an urgent referral to the trauma surgeons.
While this patient was successfully treated for his hip fracture and returned home, the fall he sustained led to unnecessary pain, a protracted recovery and added to the concern felt by his family.
6.1 Case 1: An Avoidable Patient Fall
Box 3.1 provides an overview of the events leading up to an avoidable fall on a medical ward. This 88-year-old man had multiple health problems and was admitted in a confused and distressed state. He fell while in hospital with long-term consequences for his mobility and quality of life. We could easily see his fall as simply being the consequence of his frail condition and not the fault of healthcare staff. However, whether or not we regard anyone as being at fault, this story exposes some vulnerabilities in the healthcare system.
Following the event outline above, we can identify a series of problems in the care provided and a number of wider contributory factors. Figure 3.2 provides a summary of the key error points during this patient’s admission to hospital and includes error types and contributory factors. The contributory factors in the evolution of this incident were a mixture of problems with systems, organizational, work, and team factors—the kind of issues seen in most healthcare adverse events (these are categorised according to the London Protocol in Table 3.1).
An elderly patient with sepsis is difficult to assess because of their multiple comorbidities and the difficulties of communicating with someone who is confused. The emergency department and ward were also very busy reducing the time available. Nevertheless, we can identify the following problems or ‘error points’ in the sequence of care:
Every adult over 65 years admitted to an acute hospital in the NHS should receive a falls risk assessment but it was not done properly. This patient was assessed for falls risk and was categorised (appropriately) as ‘high risk’ but no plan to reduce the risk was put in place and the information was not clearly handed over by the ED nurse to the nurse on MW.
Although at high risk of a falls the patient was placed in a bay which was difficult to observe and not kept under close observation. The Care Support Worker allocated to the bay was busy with someone else while this patient attempted to get of bed and fell.
The trainee doctor on call on the night of the fall did an appropriate assessment of the patient but did not handover his concerns about the risk of fracture adequately.
On Day 3 the patient had an additional problem (low blood pressure) another different trainee doctor (without senior assistance) reviewed the patient but was distracted by the low blood pressure and did not prioritise the investigation of the hip.
These are the principle error points (active failures in Reason’s terms) in the care of this man that played a part in both the fall and to the delayed diagnosis of fracture. We can also (Table 3.2) look at the wide range of factors that contributed to these problems occurring. These included: the frailty and confusion of the patient made assessment difficult, the inconsistent methods for monitoring and recording falls, the inexperience of the junior doctor, the lack of systematic handover, and the fact that at night the hospital has a lower nurse to patient ratio and that other elderly patients required a high level of support from the nurses on duty.
Box 3.2: An Avoidable Emergency Laparotomy in a Case of Ectopic Pregnancy
A 28-year-old woman with abdominal pain and lethargy arrived in the busy emergency department (ED) at 16:19 and was seen by a triage nurse who recorded some baseline observations and referred the patient to the ED trainee doctor, stating that she was “not worried” about the patient. The protocol for the investigation and management of early pregnancy in ED was inadequate, and there was a delay in sending the necessary blood samples for diagnosis. The track and trigger score was incorrectly calculated and follow-up observations (for heart rate and blood pressure) were, therefore, not increased in frequency resulting in a delay in calling for an expert opinion from a gynaecologist. The ED trainee doctor did not recognise the urgency of the situation and when the referral was made to gynaecology the handover did not emphasise the seriousness of the situation adequately. The trainee gynaecologist, therefore, advised that the patient be sent to the gynaecology ward for further assessment without coming to ED to see the patient.
When the patient arrived on the ward, the senior trainee gynaecologist diagnosed an ectopic pregnancy and recognised that the patient’s condition was deteriorating (her haemoglobin had dropped significantly to 99 g/L, her blood pressure was falling, and she was now complaining of shoulder tip pain). The decision was made to take the patient to theatre for emergency laparoscopic surgery and because it was now after 18:00, theatres in the main hospital were informed and the case was booked with the on-call anaesthetist. Audits had revealed that very few gynaecological emergencies came to theatre after normal working hours and consequently gynaecological patients were transferred to main theatres out of hours.
When the consultant surgeon was called (there was a 30 min delay in locating him), he agreed to come in and assist with the procedure. The patient arrived in theatre 5 h after the initial presentation with a very low blood pressure and a haemoglobin of 67 g/L. The WHO pre-list briefing was completed without the consultant gynaecologist who did not arrive until the patient was anaesthetised and being prepared for surgery by the senior trainee gynaecologist and after the ‘time out’ section of the WHO checklist.
At this time, the patient was extremely unwell and there was significantly heightened pressure to get on with the procedure. Tensions were high and when problems arose with the laparoscopy equipment (an accidentally de-sterilised light source and diathermy forceps which were incompatible with the electrical lead) behaviour deteriorated and exacerbated the stress felt by staff in theatre. The delays caused by the equipment problems necessitated a decision to convert to an open procedure which the Consultant made promptly in order to gain control of the bleeding. Once the haemorrhage was controlled and additional blood products were given the operation to remove the fallopian tube was completed uneventfully and the patient was stabilised and transferred to recovery with no further complications.
This case is similar to the one described above in that it contains the same types of contributory factors and errors that led to the eventual adverse event. The patient recovered well but had to stay in hospital longer to recover because the procedure was converted to a more invasive surgical approach.
6.2 Case 2: An Avoidable Emergency Laparotomy in a Case of Ectopic Pregnancy
Box 3.2 provides an overview of events leading up to conversion to emergency laparotomy in a young woman with an ectopic pregnancy. The case resonates with the fall described above in the sense that it would be easy to see the delayed diagnosis and treatment as a result of the patient’s youth: her cardiovascular system was able to mask the signs of shock and so medical staff did not suspect haemorrhage. It is only when we take a more holistic view of the incident that we see the latent system and organisational issues which are summarised in Fig. 3.3 along with error types.
Diagnostic challenges are a part of every medical student’s training and this case illustrates a well-recognised situation where haemorrhage is masked by the robust response of a healthy cardiovascular system. However, what is not commonly taught in medical school curricula is the risk of missing diagnoses due to distraction and system failures. This young woman’s case illustrates those problems very well:
The nurse in ED was using a poorly designed protocol for early pregnancy which did not stress the importance of urgent blood samples.
The trainee doctor had limited experience, was busy with other cases, and was influenced by the nurse’s lack of concern. He therefore did not request an urgent review of the patient.
Staffing problems in the hospital meant that emergency gynaecology cases after 18:00 had to be taken to main theatres and transfer time from the gynaecology ward was 20 min. Furthermore, no training was offered to support staff in acclimatising to the different work environment they would be in after hours.
The WHO checklist was not used adequately which led to a lack of understanding of what type of equipment would be available and no opportunity for a discussion of potential problems and their mitigations.
The gynaecologists were not used to the scrub staff or the theatre environment and equipment and when the situation became stressful the team did not function effectively and had to perform a more invasive operation to control the bleeding.
These are the principle error points leading to the emergency conversion to laparotomy in what could have been a more straightforward laparoscopic procedure. The heightened stress in this situation further impaired team function but the ‘upstream’ delays in diagnosis, staff shortages, and the physical location of the ward and theatres along with organisation of the gynaecology service out of hours all contributed to the ultimate crisis (see Table 3.3 for detailed categorisation of contributory factors).