A 24-year-old man comes to the emergency department with palpitations. He has had short-lived episodes of palpitations for several years, but this one is persistent. He has no past medical history and takes no medications. ECG shows regular narrow-complex tachycardia (QRS duration of 90 msec) at a rate of 175/min. His blood pressure is 135/80 mm Hg and physical examination is notable for tachycardia but otherwise unremarkable. Vagal maneuvers are ineffective in breaking the tachycardia. The patient receives a rapid intravenous push of adenosine (6 mg) followed by saline chaser. Soon after the bolus, his heart rate becomes 230/min and irregular, and the rhythm rapidly degenerates into ventricular fibrillation. The patient loses consciousness, and the pulse is not palpable. He is immediately defibrillated and regains consciousness. He has poor recollection of the recent events but has no other complaints. Repeat ECG shows normal sinus rhythm at a rate of 89/min, short PR interval of 110 msec, prolonged QRS complex of 130 msec, and delta waves in multiple leads. Which of the following best classifies this patient's encounter?
A)Medicolegal error
B)Near-miss
C)Negligent adverse event
D)Non-preventable adverse event
E)"Save" event

Question

A 24-year-old man comes to the emergency department with palpitations.  He has had short-lived episodes of palpitations for several years, but this one is persistent.  He has no past medical history and takes no medications.  ECG shows regular narrow-complex tachycardia (QRS duration of 90 msec) at a rate of 175/min.  His blood pressure is 135/80 mm Hg and physical examination is notable for tachycardia but otherwise unremarkable.  Vagal maneuvers are ineffective in breaking the tachycardia.  The patient receives a rapid intravenous push of adenosine (6 mg) followed by saline chaser.  Soon after the bolus, his heart rate becomes 230/min and irregular, and the rhythm rapidly degenerates into ventricular fibrillation.  The patient loses consciousness, and the pulse is not palpable.  He is immediately defibrillated and regains consciousness.  He has poor recollection of the recent events but has no other complaints.  Repeat ECG shows normal sinus rhythm at a rate of 89/min, short PR interval of 110 msec, prolonged QRS complex of 130 msec, and delta waves in multiple leads.  Which of the following best classifies this patient's encounter?
A)Medicolegal error
B)Near-miss
C)Negligent adverse event
D)Non-preventable adverse event
E)"Save" event

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0dc_0d63_8f63_f50b35e34e94_MD0005_00 This patient presented with supraventricular tachycardia and was managed appropriately with vagal maneuvers followed by intravenous adenosine to attempt acute termination of the tachycardia. Unfortunately, he turned out to have underlying Wolff-Parkinson-White (WPW) syndrome, given his repeat ECG showing a short PR interval, wide QRS complex, and delta waves. In patients with WPW syndrome, adenosine administration can provoke atrial fibrillation with rapid conduction via the accessory pathway, which can eventually degenerate into ventricular fibrillation, as occurred in this patient. Although adenosine should not be used routinely in patients with WPW syndrome, at the time of the patient's initial presentation, the providers would not have known that he had underlying WPW syndrome. The patient was treated appropriately with adenosine and subsequently developed rapid atrial fibrillation that degenerated into VF as a rare and potentially lethal side effect of adenosine in the setting of WPW syndrome. This is a classic example of non-preventable adverse effect in the setting of the appropriate use of medications for approved indications. (Choices A, B, and E) Medical error is a broad category that includes diagnostic errors (eg, missed or misdiagnosis) and therapeutic errors (eg, ordering or administration of inappropriate medical treatment). Medical errors can be recognized early and never reach the patient ("saves"), can reach the patient but cause no apparent harm ("near misses"), or can lead to a potentially serious event ("preventable adverse event"). Preventable adverse events occur as a result of failure to follow evidence-based best practice guidelines at the individual and/or system level. (Choice C) Negligent adverse event is a category of preventable adverse event that occurs due to gross negligence on the part of health care providers. An example of a negligent adverse event would be a drug reaction in a patient who received a drug despite having a known allergic reaction to that particular drug. The patient in the vignette was appropriately treated with adenosine for narrow-complex regular tachycardia; therefore, the development of VF is not considered a negligent adverse event. Educational objective: Preventable adverse events occur from failure to follow evidence-based best practice guidelines. Non-preventable adverse events are complications that cannot be prevented given the current state of medical knowledge and occur despite appropriate medical practice. References: The spectrum of medical errors: when patients sue. (http://www.ncbi.nlm.nih.gov/pubmed/22924008) Classification of medical errors and preventable adverse events in primary care: a synthesis of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/12485545)

A 24-Year-Old Man Comes to the Emergency Department with Palpitations