Using the Swiss Cheese Model (PSNet), you will analyze all the “holes” in the case. Your goal is to analyze each “smaller” failure that ultimately led to the catastrophic event.
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Scenario
Patient XYZ is a healthy 40-year-old man scheduled for the removal of a benign stomach tumor. He was admitted to the pre-operative holding area, where his nurse quickly went through his history. He did not report a significant medical history, did not have drug/latex allergies, and only took a multivitamin daily. His vital signs were all normal. His labs were normal except for his potassium result was low. The RN reported this to the physician who ordered a bolus of intravenous potassium to be given in the operating room (OR) by anesthesia. After speaking with anesthesia and signing consents, the patient was rolled back to the OR.
A time-out procedure was conducted. Anesthesia’s cart had been stocked the night before by a brand-new pharmacy technician. The pharmacy has been super busy, so the pharmacy tech was asked to get this OR done independently, as his training was nearly completed. Anesthesia had two IV bags, one with pre-op antibiotics, and the other was normal saline that he would use to self-mix the ordered potassium.
Intubation ended up being difficult, so the RN was asked to mix the potassium. The anesthesiologist said, “Just pull up the vial in the top right drawer. This is where the correct dose of potassium is kept.” The RN did just this: reconstituted the vial and inserted it into the IV bag. The five rights of medication administration were more implied than done; after all, the anesthesia provider was standing right there. Anesthesia quickly hung the bag and continued to support the patient’s airway. The surgery was performed seamlessly. The surgeon was preparing to close when asystole was noted on the monitor. Anesthesia commented that a lead must have come off.
The carotid artery was subsequently checked, and no pulse was detected. A code blue was called, with the suspected cause being hemorrhage. However, the abdomen was still open, and active bleeding was not detected. Nonetheless, a fluid bolus was given, oxygen saturation was checked and titrated to 100%, and yet, the asystole continued. As the surgeon continued to manage the code, someone mentioned the potassium that was given. The RN went to the trash to retrieve the vial of medication.
Upon examination, it was noted that the potassium concentration used was more than 100x the recommended dose- enough to stop a heart. So, a lethal dose of potassium had been given. Seeing as the code was still in progress, the medical team quickly converted to interventions that required lowering potassium (injections of glucose and insulin, IV calcium). Luckily, the patient’s heart responded, and a heartbeat with normal sinus rhythm was detected. Hours later, it was determined that the patient did not have cognitive deficits. https://psnet.ahrq.gov/taxonomy/term/3460. Analyze 5 errors/misses that led to the patient’s asystole.
How Did the Swiss Cheese Holes Align? A Critical Analysis of Failures Leading to Patient XYZ’s Catastrophic Event
The Swiss Cheese Model of accident causation, first introduced by James Reason, is widely used in risk analysis across industries, including healthcare. It posits that multiple layers of defense and safeguards exist in high-risk systems, akin to slices of Swiss cheese. However, each layer contains holes, or weaknesses, that can align under specific conditions, leading to catastrophic outcomes. Using this framework, we critically analyze the chain of events that led to Patient XYZ’s near-fatal outcome, with a focus on five critical errors. These errors represent “holes” in the layers of systemic and individual defenses.
The first error occurred during pre-operative management when Patient XYZ’s low potassium levels were identified but not sufficiently addressed. Hypokalemia, or low potassium levels, can increase the risk of cardiac arrhythmias. While the reporting RN correctly flagged the lab result, the decision to administer intravenous potassium during the surgery instead of correcting it beforehand introduced unnecessary risk.
Incomplete Risk Assessment: The decision to administer potassium in the operating room (OR) reflects a lack of thorough risk assessment. Managing hypokalemia in a controlled, pre-operative setting could have mitigated potential complications.
Normalization of Deviance: The assumption that potassium could be safely administered in the OR without strict monitoring reflects a normalization of deviance, wherein risky shortcuts become routine over time.
Over-Reliance on Anesthesia: The responsibility for potassium administration was deferred to anesthesia without adequately considering whether they had the bandwidth to safely manage this additional task in the OR’s high-stress environment.
According to a study by Henneman et al. (2010), communication breakdowns and failure to address abnormal lab results are among the most common contributors to perioperative errors. Additionally, pre-operative optimization of electrolytes is a standard guideline in perioperative care (American Society of Anesthesiologists, 2020). This lapse exemplifies how systemic inefficiencies and overconfidence in procedural norms can exacerbate patient risk.
The second significant failure occurred in the pharmacy. A new pharmacy technician, nearing the end of their training, was tasked with independently restocking the anesthesia cart under busy conditions.
Insufficient Training: The pharmacy technician’s training was nearly complete but evidently insufficient. They lacked the experience and oversight necessary for a high-stakes task such as restocking medications for the OR.
Workload and Staffing Issues: The pharmacy’s busy environment likely compromised the quality of oversight. Delegating this critical task to an unverified technician reflects poor resource allocation and prioritization.
Absence of Double-Check Protocols: A robust double-check system could have caught the error before the high-concentration potassium vial was placed in the anesthesia cart.
A 2019 report by the Institute for Safe Medication Practices (ISMP) highlights that insufficient training and lack of double-check protocols are significant contributors to medication errors. Furthermore, the World Health Organization’s (WHO) Medication Without Harm initiative emphasizes the importance of adequate supervision and staff competency in reducing errors.
The third critical failure involved the reconstitution and administration of the high-concentration potassium vial by the RN without adhering to the Five Rights of Medication Administration: right patient, right drug, right dose, right route, and right time.
Implied Practices over Explicit Verification: The RN relied on the anesthesiologist’s verbal instruction to use “the vial in the top right drawer” without independently verifying the drug or dose.
Cognitive Overload in the OR: The OR’s high-pressure environment, compounded by the difficult intubation, likely distracted both the RN and the anesthesiologist from performing necessary checks.
Normalization of Deviance: The casual approach to medication preparation, bypassing standard protocols, reflects a culture where safety procedures are inconsistently followed.
Studies by Hughes and Blegen (2008) underline that failure to adhere to the Five Rights is a leading cause of medication errors. These errors account for approximately 7,000 deaths annually in the United States (National Coordinating Council for Medication Error Reporting and Prevention, 2021). Simulation-based training programs have proven effective in reinforcing adherence to these principles in high-stress environments.
A significant lapse occurred when the anesthesiologist delegated the preparation of potassium to the RN. This delegation was inappropriate, given the complexity and risks associated with mixing high-concentration medications.
Inappropriate Task Delegation: The anesthesiologist’s decision to delegate this task to the RN was influenced by the immediate need to manage the airway during a difficult intubation. However, this shifted a critical task to someone less familiar with the specific requirements.
Assumption of Competence: The anesthesiologist assumed that the RN would follow correct procedures without explicitly verifying the prepared solution.
Lack of Redundancy: The absence of a second layer of verification—either through another healthcare professional or a pre-set protocol—allowed the error to go unchecked.
Research by Gaba et al. (2001) on human factors in anesthesia highlights how task saturation and poor delegation contribute to errors. The Joint Commission’s Universal Protocol (2018) advises against delegating critical tasks without sufficient checks.
The final and perhaps most systemic error involved the labeling and storage of high-concentration potassium vials. The placement of such a dangerous drug in a general anesthesia cart without clear labeling or segregation was a latent error waiting to align with active failures.
Inadequate Storage Practices: High-concentration potassium should be stored separately from general-use medications to prevent accidental selection.
Poor Labeling Standards: The vial lacked distinct, high-visibility labeling to alert healthcare providers to its dangerous concentration.
Failure to Implement Safety Recommendations: Despite long-standing guidelines from organizations like the ISMP, the healthcare facility failed to adopt best practices for managing high-alert medications.
The ISMP has consistently recommended segregating high-alert medications and using auxiliary labels to minimize the risk of errors. A study by Leape et al. (1995) found that 70% of medication errors could be prevented by improving labeling and storage practices.
The case of Patient XYZ underscores how multiple “holes” in the Swiss Cheese Model can align to create a near-fatal event. While individual errors played a role, systemic issues amplified their impact. Addressing these weaknesses requires both immediate corrective actions and long-term cultural changes.
Pre-operative management should prioritize correcting electrolyte imbalances in a controlled setting. Establishing clear guidelines and decision trees for managing abnormal lab results can prevent similar lapses.
Pharmacy technicians should undergo rigorous training with supervised practice. Implementing mandatory double-check protocols for restocking high-alert medications can add a critical layer of safety.
Healthcare facilities must invest in regular training and simulation exercises to reinforce adherence to the Five Rights of Medication Administration. Introducing barcode scanning systems could further reduce errors.
Anesthesia providers and nurses should receive training in effective task delegation and closed-loop communication. Team-based simulation scenarios can prepare staff for high-pressure situations.
Hospitals must adopt ISMP guidelines for segregating and labeling high-alert medications. Regular audits should ensure compliance with these practices.
The near-fatal event involving Patient XYZ highlights the fragility of healthcare systems when latent errors align with active failures. Using the Swiss Cheese Model as a framework, this analysis underscores the importance of addressing both individual and systemic vulnerabilities. By implementing targeted interventions and fostering a culture of safety, healthcare organizations can minimize the risk of such catastrophic events.
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