Inquiry into Patient Death
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Case Study ‘Clinical Detective’
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Report for the Bunbury Regional Hospital’s quality and safety committee into the death of Josephine Wilma Troy
This report has been prepared for the Bunbury Regional Hospital’s quality and safety committee, following the death of Josephine Wilma Troy on 14 February 2006. Mrs. Troy was a 63 year old lady who had been diagnosed with leukemia in 2004 and was treated with chemotherapy initially. The diagnosis was later refined to prolymphocytic leukemia, a rare chronic leukemia, as Mrs. Troy’s leukemia persisted in her bone marrow after an initial course of chemotherapy. Disease together with chemotherapy compromised her blood production capacity. She had low white blood count, low platelet count and low hemoglobin and was susceptible to infection and febrile neutropenia. Mrs. Troy had been issued with febrile neutropenia card to warn health care workers regarding her susceptibility to febrile neutropenia.
On 12/02/2006, Mrs. Troy had a temperature of 38°C and attended Bunbury Regional Hospital with her card. She was started on antibiotic and a full blood screen was ordered in view of her susceptibility to febrile neutropenia. She recorded a very low platelet count (3), which required a platelet transfusion. She was admitted to St. John of God Hospital, Bunbury for treatment of neutropenia sepsis. The following day her platelet count dropped even lower (1). An order was placed for platelet from Australian Red Cross Blood services. She was transfused with two units of blood. There was apparent improvement in her condition after the blood transfusion. In the early hours of 14/02/2006, Mrs. Troy suffered a significant deterioration in her condition. The platelets were transfused in the morning of 14/02/2006. However Mrs. Troy suffered a catastrophic intracranial bleed and did not recover from it.
This report will look in to the events that lead to death of Mrs. Troy and critically evaluate the key findings. Finally it will make recommendations to reduce the reoccurrence of similar adverse event. It is expected that the recommendations will be examined and will be included in to clinical guide lines and policies by this hospital and other hospitals.
As a registered nurse in charge of the ward the facts resulted in the adverse event need to be evaluated. Discussions have taken place with health care providers who were in charge of Mrs. Troy and patient’s records have been assessed in order to gather information for this report.
- Description of Models
Two theories were used in examining the findings namely the Human Factors Model and the Swiss Cheese Model. According to United Kingdom health and safety executive, human factors refers to” environmental, job or organisational factors and human and individual characteristics and how they influence on individuals health and safety related behavior (Health and Safety Executive, 1999, p.2 as cited in World Health Organisation, 2009)”. It inspect the relationship between human being and the system they interact with and focus on improving productivity, job satisfaction, efficiency and minimising errors (Patients Safety First,2010).
The Swiss cheese model evaluates a chain of events that lead to an error to learn from the errors (National Council of State Board of Nursing, 2011). It explains that there are many levels of defence in a system like checking of medication before administration, marking surgical site, guidelines, experienced staff etc. (NCSBN, 2011). If these defence barriers are in place it prevent the error form happening. But in reality the defences are full of holes like poor communication, lack of guidance etc. (Reason, 2000). These holes are known as latent conditions or active failures. Active failures have immediate and direct effect on the outcome as it is the unsafe act committed by the individual who are in direct contact with the patient or system (Reason, 2000). Latent conditions are resident errors within the system as they arise from the decisions made by the top management. They may stay in the system for many years before create an error. Examples include staff shortage, high workload. When all levels of defence are penetrated by a combination of active failure and latent conditions a patient safety incident will occur.
Identifying the active failures is the first step in assessing the events leading to Mrs. Troy’s death. This will help in identifying the underlying latent conditions.
- Active failures
Mrs. Troy’s change of diagnosis, (from acute lymphobastic leukemia to prolymphocitic leukemia) did not document in progress note.
Unawareness of Health care professional involved in Mrs. Troy regarding her stay during the intensive monitoring period. She resided in Bunbury instead of Fremantle.
Dr. Webb didn’t communicate his expectation of Mrs. Troy to remain in Fremantle area for easy access to hospital in case of complications.
Mr. Mclntyre failed in requesting to order urgent platelet when he had a clear understanding of the relevance of a low platelet count.
Even though Mrs. Troy had experienced an extreme low platelet count nothing was done by the staff to provide transfusion as soon as possible.
Dr. Terren was not provided with the observation that Mrs. Troy’s temperature had raise to 40°C.
Dr. Terren didn’t mark urgent on the original request form for platelet.
Mr. Bastow did not advice Dr. Terren that platelet could be obtained earlier than the next day in case of emergency.
- Latent conditions
- Failures in communication
Communication breakdown has occurred at various stages of this case. Mrs. Troy’s change of diagnosis, (from acute lymphobastic leukemia to prolymphocitic leukemia) and its significance in change of life expectancy and treatment regime did not communicated to her and her family which caused lots of misunderstanding to her family. Dr. Webb didn’t communicate his expectation of Mrs. Troy to remain in Fremantle area for easy access to hospital in case of complications. There was a clear misunderstanding about discharge and discharge home between Mrs. Troy and the hospital staff. Mr. Bastow did not communicate to Dr. Terren that platelet could be obtained earlier than the next day in case of emergency.
- Failures in documentation
Mrs. Troy’s change of diagnosis, (from acute lymphobastic leukemia to prolymphocitic leukemia) did not document in progress note. The letter to Mrs. Troy’s GP would only be placed in her file once typed following Dr. Webb’s outpatient clinic. The disadvantage with this practice was Fremantle staff did not have access to Dr. Webb’s revised management plan at the time they saw Mrs. Troy.
- Inadequate basic training
Lack of knowledge about complication of low platelet count and procedures regarding request for urgent platelet from Australian Red Cross Blood service were evident. This resulted in delay in providing transfusion at the most critical phase. Dr. Terren was not provided with the observation that Mrs. Troy’s temperature had raise to 40°C.
- Inadequate staffing
There was only one medical scientist available. He was not on duty when nursing staff tried to collet platelet. This caused further delay in transfusion as platelets could not be collected before they had been properly checked by medical scientist.
A combination of leadership attributes are necessary to do a successful investigation of the events leading to Mrs. Troy’s death. Transformational and effective leadership is essential for success in a healthcare organisation (Huber, 2010). Flexibility is one of the attributes. The investigator should be able to adapt to a challenging situation. Be a good communicator in order to obtain as much as information about the event and to consider all options (Marshall, 2011). Open- minded to evaluate inputs from all interested parties in decision making. Be able to utilise all the resources available. Investigator should be well educated on policies procedures and organisational norms (Huber, 2010). Investigator should be a good evaluator. Good evaluation of events is necessary for an organisation to improve, to change programs and policies that are not working (Daly, Speedy and Jackson, 2004). Critical thinking and problem solving skills are essential to achieve success (Sullivan and Decker, 2005).
- Febrile Neutropenia medical alert card should indicate patient’s current diagnosis in order to provide adequate information at critical situation and to facilitate necessary treatment.
- Current diagnosis, treatment plan and expected outcome should discuss with patient and family to avoid misunderstanding and to take necessary precautions in case of complications.
- Employment of adequate number of medical scientists to prevent delay in checking platelets before administration. A medical scientist should present in the hospital at all times.
- Current diagnosis and new treatment plan should indicate in patient’s progress note immediately following consultation.
- Basic training should be given to staff regarding complication of low platelet count, necessary observations, proper way of ordering and obtaining platelet in case of emergency.
- Guidelines to obtain blood product from ARCBS should be readily available in all wards.
- Protocols regarding platelet transfusion (like platelet transfusion should be commenced if platelet count is below 10X/L for chemotherapy patients) should be kept visible in all wards (Slichter, 2007).
Numerous preventable factors were identified during the analysis of Mrs. Troy’s case. When latent conditions combined with active failures, they created multiple holes in the defence barrier. When these holes aligned together the tragic death of Mrs. Troy occurred. More effective defence has been recommended to ensure that these holes do not open and align again. The recommendation includes proper communication, adequate documentation of current treatment plan and diagnosis, employment of adequate staff, availability of guidelines and protocols and adequate basic training of the staff.
The best way to prevent errors is to identify and remedy the underlying system failures rather than blaming individual (Sullivan and Gerald, 2010). Every health care professional have the responsibility to learn, to improve and to provide safe healthcare to the patients under their care.
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