It Could Happen to Anyone – Why I’m Attending

As I imagine several other people here attending can relate, I have long been a “fixer.“ Rather, I have always wanted to be a fixer, but throughout the years I came to realize what I could and couldn’t control and where I could actually make a difference. I was intrigued by quality improvement and patient safety because it simply made sense. You assess a situation or adverse event, and you get to the root cause of everything that led up to that event before trying to create a solution. So much in medicine is unknown and our research processes are hypothesis-driven based on what we think we already know about a subject. But with QI, we have the humbling benefit of seeing the end result of a situation and being able to work backwards to understand what led to it. With that information you can test a hypothesis or intervention and have direct feedback on whether you correctly identified the issue or have actually made a difference. Although the QI projects I have participated in so far have been relatively small, seeing that we can create effective change inspired me to continue learning more about QI so that I might bring about real change in bigger patient safety related issues.

One near miss I had occurred while I was a senior resident on the night service for internal medicine. My intern and I admitted a patient for an unrelated issue who also had chronic malignancy-related pain and a palliative subcutaneous pain pump that needed to be continued during her hospital stay. When I reviewed the admission orders with my intern, I noticed that the Dilaudid prescription from the home medication reconciliation was a very high dose and it didn’t seem right. I personally verified the orders from the outpatient list showing intravenous Dilaudid continuously with prn doses every so often. It still seemed quite high so I went to the patient’s room, spoke with her, and read the doses straight off her home bag of Dilaudid and verified it was correct. Still not convinced, I called the pharmacist and asked if they had seen doses this high administered and they said it was possible, though it was indeed high. Having done everything I thought I could, we placed the orders for the IV Dilaudid as they were ordered outpatient, so the patient could be transitioned to a hospital IV pole and pump. After staffing, I later received a call from the attending asking about the pain pump. When she went to round on the patient, the nurses had an alarm on the hospital pump which said the dose was too high and could only be overridden by a physician. My attending quickly realized that the patient’s pump delivered Dilaudid subcutaneously, not intravenously as was written in the outpatient orders and continued by me. Thankfully, we were able to convert to subcutaneous equivalent dosing and the patient did not experience any harm. But I was quite shaken by the event knowing that I could have potentially ordered a lethal dose of medication for a patient, despite doing everything I could to verify that the order was correct.

As I learned more about QI and system issues that create environments for individuals to make mistakes, I became more interested in figuring out solutions which would outlast my time as a current employee of my hospital. Even though I strive for excellence and personal growth, I am still human and therefore make mistakes. And if I can make mistakes and cause harm, then members of our healthcare teams who are less motivated or equipped to handle certain situations are even more at risk of adverse events. Still, every day they are operating in a system that has expectations they may not be able to meet and therefore potentially putting patients in harm’s way. My hope is to learn more about how we can change our culture and systems to keep our patients safe.