Abstract
The sentinel event that is the basis of this RCA paper is the Lewis Blackman case. Lewis had pectus excavatum and was taken into a teaching hospital for an operation to fix his condition (“Patient story,” n.d.). Lewis experienced severe pain after the operation and was put on opioids and Toradol. On the third day, he experienced severe pain in his stomach area, which the nursing staff diagnosed as ileus.
The patient’s condition worsened, his blood pressure dropped, and he became pale. However, the medical personnel never contacted an attending physician to review Lewis’ case. On the fourth day after the surgery, Lewis had a cardiac arrest and died. The autopsy showed that he had a perforated duodenal ulcer, which is a complication from Toradol. The Lewis Blackman case is a scenario where lack of experience and negligence from the medical personnel, which led to an inaccurate assessment of vital signs and a decision to modify the pulse oximeter settings resulted in an inaccurate assessment and patient’s death.
Introduction
The issue that this RCA address is the negligence from the medical personnel that led to them missing signs of perforated duodenal ulcer. Firstly, Lewis was in a teaching hospital, which means that the majority of physicians were in their first years of training and professional work. They did not treat Lewis’s case seriously, since at first, his low oxygen saturation was attributed to asthma, and the pulse oximeter was set to 85% and eventually turned off (“Patient story,” n.d.). Moreover, the staff failed to acknowledge that this patient’s case is serious, and they did not contact an attending physician to review Lewis’s vital signs, even after they could not measure his blood pressure. Finally, a perforated duodenal ulcer is a common and deadly complication of Toradol, a pain medication that Lewis was put on.
However, the medical personnel failed to check if this patient was affected. As a result, Blackman underwent septic shock and died. Hence, this paper will address the negligence and failure to provide proper care by the staff of the teaching hospital where Lewis Blackman underwent surgery, which led to his death.
Root-Cause-Analysis
The method of analysis applied in this paper to identify the underlying problem that led to Lewis’ death is the RCA. RCA is a “is the process of discovering the root causes of problems in order to identify appropriate solutions” (“Root cause analysis explained,” n.d., para. 12). Additionally, Figure 1 is a fishbone diagram that illustrates the scenario and the varied factors that led to Lewis’s death. Hence, through root cause analysis, the issues that led to Lewis’s death will be identified.
The issue in question is the septic shock that led to Lewis’s death on the fourth day after his minor surgery. The factors displayed in Figure 1 that led to this outcome are no supervision, lack of experience of the physicians who monitored Lewis, protocols of this hospital, vital signs assessment failures, communication problems, and equipment. Hence, since this hospital allowed trainees to work freely on patient cases and the latter did not question their ability to diagnose cases properly, they failed to assess patient’s vitals and even turned off the oxygen monitor and did not pay attention to the blood pressure monitor’s results. Moreover, the physicians did not communicate with their experienced colleagues and ignored parents’ concerns about urination decrease.
Some terms that are important for this case are perforated duodenal ulcers, which are open sores that develop in the intestine or stomach. This ulcer led to the development of sepsis, and septic shock, which is a result of an infection that leads to a drastic blood pressure drop. Toradol is a brand name of the pain medication Ketorolac, which is an anti-inflammatory drug used to manage pain.
When interpreting the information from this case study, it is evident that there are several systemic errors that resulted in the failure to recognize the patient’s septic shock and prevent his death. Firstly, the physicians made several assumptions about Lewis’s state that were not backed by adequate data, vital signs assessment, or an attending physician. Second, the patient was put on IV pain killer medication without adequate fluids or a recognition of the potential side effects from Toradol, which points to a lack of protocols in this hospital that would require physicians to monitor patients on this medication more closely. Finally, the miscommunication was a serious problem as Lewis’s parents voiced concerned about the decreased urination; the personnel did not pay attention to this symptom. Moreover, the medical staff and the parents did not communicate clearly over the course of this case.
Why Does This Exist?
The problem of negligence is a result of two factors, the first one is improper supervision at the training hospital, and the second is the inability of the young physicians to acknowledge their lack of experience and expertise. These two factors led to the staff failing to acknowledge that Lewis’s symptoms were not consistent with the standard postoperative side effects and request an opinion of the attending physicians. This is a long-term problem in the healthcare system since there is a lack of medical professionals overall, which is a potential reason why the inexperienced physicians were not supervised. Additionally, the systemic errors are a result of the inadequate protocols in a hospital that would require checking patients who undergo even minor surgeries. Following the five why’s approach, these conclusions can be made:
- The patient died from septic shock.
- The development of sepsis was not recognized.
- Vital signs, such as oxygen saturation and blood pressure, were ignored.
- The personnel was inexperienced and did not request assistance.
- Hospital rules and protocols did not outline the management of patients on Toradol and allowed trainees to work with complicated patients unsupervised.
Rationale
There are examples of patient cases where the latter developed duodenal ulcers and had severe bleeding linked to the use of Toradol. For example, Pham et al. (2020) report a patient case of an 80 years old man undergoing orthodontic surgery who developed duodenal ulcers as a result of using non-steroid pain medication. The side effects of Toradol are well-examined, and Hutka et al. (2021) report that “nonsteroidal anti-inflammatory drugs (NSAIDs) induce significant damage to the small intestine, which is accompanied by changes in intestinal bacteria (dysbiosis) and bile acids” (p. 664177).
Moreover, Russo et al. (2017) state that the prolonged use of Ketorolac is advised against since it is associated with adverse kidney and gastrointestinal events. Finally, it is evident that in this case, the personnel failed to recognize the signs of septic shock. According to Backer et al. (2021), these are decreased urination, blood pressure issues, and paleness. All of these signs were present on the third day after Lewis’s surgery.
Conclusion
In summary, this paper focuses on the issues of negligence and hospital policies leading to Lewis Blackman’s death are discussed. Some recommendations include ensuring that the hospital policies highlight the potential side effects of Toradol. Additionally, the trainees must report any sudden or unusual changes in the patient’s vital signs to attending physicians. Even minor surgery patient cases should be closely monitored and reviewed by supervisors.
References
De Backer, D., Ricottilli, F., & Ospina-Tascón, G. (2021). Septic shock: A microcirculation disease. Current Opinion in Anaesthesiology, 34(2), 85-91. Web.
Hutka, B., Lázár, B., Tóth, A., Ágg, B., László, S., & Makra, N. (2021). The nonsteroidal anti-inflammatory drug ketorolac alters the small intestinal microbiota and bile acids without inducing intestinal damage or delaying peristalsis in the rat. Frontiers in Pharmacology, 12, 664177. Web.
Patient story. (n.d.). Web.
Pham, M., Dunlop, N., Pham, L., & Turvey, T. (2020). Severe bleeding from a duodenal ulcer after orthognathic surgery: A case report. International Journal of Oral and Maxillofacial Surgery, 49(6), 794-796. Web.
Root cause analysis explained: Definition, examples, and methods. (n.d.). Web.
Russo, R., De Caro, C., Avallone, B., Magliocca, S., Nieddu, M., & Boatto, G. (2017). Ketogal: A derivative Ketorolac molecule with minor ulcerogenic and renal toxicity. Frontiers in Pharmacology, 8, 20-30. Web.