A 63-year-old man admitted for urolithiasis complicated by a urinary tract infection is treated with intravenous antibiotics. The patient is a Russian-speaking immigrant who lives with his son. During the night, the nurse sees that one of his intravenous catheters is infiltrated and cannot be used. The nurse is unable to secure a second peripheral intravenous line and notes that the patient is becoming progressively hypotensive with a blood pressure of 105/50 mm Hg and pulse of 89/min. He calls the medical resident covering the patient for assistance. The resident has little experience placing peripheral intravenous lines but has placed several internal jugular lines, including 5 independently, during his intensive care rotations. The resident asks the patient in English for consent of immediate central line placement. During the attempt to insert the internal jugular line, the patient develops a large pneumothorax. In the root cause analysis of this adverse event, which of the following could be the most important patient-related factor?

Question

A 63-year-old man admitted for urolithiasis complicated by a urinary tract infection is treated with intravenous antibiotics.  The patient is a Russian-speaking immigrant who lives with his son.  During the night, the nurse sees that one of his intravenous catheters is infiltrated and cannot be used.  The nurse is unable to secure a second peripheral intravenous line and notes that the patient is becoming progressively hypotensive with a blood pressure of 105/50 mm Hg and pulse of 89/min.  He calls the medical resident covering the patient for assistance.  The resident has little experience placing peripheral intravenous lines but has placed several internal jugular lines, including 5 independently, during his intensive care rotations.  The resident asks the patient in English for consent of immediate central line placement.  During the attempt to insert the internal jugular line, the patient develops a large pneumothorax.  In the root cause analysis of this adverse event, which of the following could be the most important patient-related factor?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1ef_79c9_8f63_2f82b020f93d_MD0005_00 Root cause analysis (RCA) is an important quality improvement tool to identify the multiple influencing factors behind undesirable outcomes, with the goal of recommending corrective measures. RCA provides a framework to analyze and categorize various contributory elements by general groups, such as patient, staff, task, equipment, and work environment; this allows for more complete understanding and prioritization of potential solutions. Examples of patient-related factors include clinical condition; cultural or religious beliefs; language; state of emotional distress; and various interpersonal relationships with family members, loved ones, and the medical team. Although many factors (eg, lack of translation services, lack of resident training in peripheral access management, nursing workloads) likely contributed to the adverse event in this case, the most likely patient-related contributing factor is the language barrier between the treating physician and patient. This barrier can diminish discussion of the risks, operator experience, benefits, and alternate approaches. It may have led to the clinical decision for an intervention with which the resident was more comfortable (central line) instead of an intervention more appropriate for the patient's clinical situation (more peripheral access). (Choice A) The absence of an attending physician to supervise a trainee during a nighttime procedure is an education and training factor that may have contributed to an unsafe practice on the part of the trainee. (Choice B) The availability of appropriate equipment to reduce the risks of a procedure is an equipment factor. (Choice D) The patient's support system can affect clinical decision making and the choices that patients make regarding their care. However, this patient's living situation and support network likely had less relevance than the language barrier in the decision to place a central venous catheter overnight. (Choice E) The medicolegal environment is a broader institutional factor and not patient specific. Educational objective: Root cause analysis is an important quality improvement tool to understand adverse events and identify the reasons behind undesirable outcomes, with the goal of recommending corrective measures. Systematically categorizing various factors allows for more complete understanding and prioritization of potential solutions. References: Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/22421911) Medical errors and clinical risk management: state of the art. (http://www.ncbi.nlm.nih.gov/pubmed/16749601) Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. (http://www.ncbi.nlm.nih.gov/pubmed/21949441)

A 63-Year-Old Man Admitted for Urolithiasis Complicated by a Urinary