HLTH5633 Module 1 event analysis paper example

A Potassium of 6.9 That Nobody Acted On for Three Hours: An Event Analysis of the System Conditions That Let a Critical Result Reach a Patient

Student Name

American College of Education

HLTH5633: Advanced Quality Management for Healthcare Administrators

Module 1 Assignment

Instructor Name

July 3, 2028

The Event

A 74-year-old man who has chronic kidney disease came in with pneumonia and went to a 32-bed medical unit at a 260-bed community hospital. Everyone and everything in this case is invented for the assignment. His admission potassium was 5.2 mmol/L. He received potassium-sparing medications continued from home, and at 1805 on his second hospital day blood was drawn for a basic metabolic panel. At 1847 the laboratory resulted a potassium of 6.9 mmol/L, a critical value under hospital policy.

At 1851 a laboratory technologist called the unit's main telephone to report the result. The call was answered by the unit secretary, who was also covering the admissions desk during shift change. The secretary wrote the value on a sticky note, read it back, and placed the note on the charge nurse's desk. The day charge nurse had already begun report, and the night charge nurse did not see the note until 2105. The patient's nurse, who was caring for five patients, had not reviewed new results during handoff. At 2150 the patient became bradycardic and then pulseless; he was resuscitated after four minutes and transferred to intensive care, where he survived with no apparent neurological injury. A repeat potassium at 2200 was 7.3 mmol/L.

A Model of How Failures Line Up

Reason (2000) contrasts two ways organizations explain error. One looks for the individual who slipped and answers with discipline or more training; the other starts from the premise that everyone makes mistakes and asks what features of the workplace made this one likely. In his well-known image, an organization's defenses are like slices of cheese with holes in them; harm occurs when the holes in successive defenses line up, allowing a hazard to pass through. The holes arise from active failures, the errors of people at the front line, and from latent conditions, weaknesses built into the system by design, staffing, policy and technology decisions made elsewhere.

Current guidance on root cause analysis takes the same view. The National Patient Safety Foundation (2015) recommended that event reviews focus on identifying system vulnerabilities and on stronger actions, such as design changes and forcing functions, rather than weaker actions such as policy reminders and training, which depend on people remembering to do the right thing. If the analysis ends with the secretary, the charge nurse or the patient's nurse, it will have found the last hole, not the reason the holes lined up.

The System Conditions

The analysis team, which included the laboratory director, the unit manager, a unit secretary, two nurses and a hospitalist, identified five system conditions that allowed the result to reach the patient without action. First, the notification process allowed a critical result to be given to any person who answered the unit telephone, rather than requiring it to reach the licensed caregiver responsible for the patient. The read-back confirmed that the message was heard correctly, not that it reached someone who could act. Second, the call occurred during shift change, when the charge nurse role was in transition and the unit's usual attention to incoming information was lowest. The laboratory had no way of knowing that, and the unit had no process for pausing handoff for critical calls.

Third, the unit secretary was covering two roles at once because a second secretary position had been vacant for four months. Fourth, the electronic record displayed the critical result only in the results tab, without an alert to the patient's nurse or physician, because the hospital had turned off critical result pop-ups two years earlier after complaints about alert volume. Fifth, the medication orders for the potassium-sparing drugs were continued automatically at admission without a prompt to reassess them in a patient with kidney disease and a rising potassium.

National data suggest that the laboratory itself was not the slow step. A College of American Pathologists study of 121 institutions found that the median laboratory took about five minutes to notify someone of a critical result once testing was complete (Valenstein et al., 2008). In this event, the laboratory called four minutes after the result was final. The delay occurred after the notification, inside the unit.

Contributing Factors and Root Causes

Not every condition is a root cause. The vacant secretary position and the timing of the call at shift change were contributing factors: they made failure more likely but would not have caused it if the notification process had been designed to reach a licensed caregiver. The team identified two root causes, the conditions that, if corrected, would most likely have prevented the event or its recurrence. The first is a notification process that treats any person answering a telephone as an acceptable recipient of a critical result. The second is the absence of any electronic backstop, because critical result alerts had been removed to reduce alert fatigue without a replacement for the most dangerous values.

Both root causes are latent conditions created by decisions made for good reasons: the telephone process was efficient, and turning off pop-ups responded to real complaints about alerts that nurses ignored. The analysis does not criticize those decisions; it shows that together they left no defense that did not depend on a person seeing a sticky note.

What Would Be Strong Enough

The actions follow from the root causes. The strongest is to require that critical results be communicated directly to the responsible licensed caregiver, with the laboratory calling the patient's assigned nurse on a unit-issued mobile phone and escalating to the charge nurse and then the hospitalist if the nurse does not answer within ten minutes. The second is to restore an electronic alert for a small set of the most dangerous critical values, including potassium above 6.0 mmol/L, sent to the patient's nurse and physician and requiring acknowledgment. Weaker actions, such as reminding secretaries to hand messages directly to nurses, would be added only as supplements. Filling the vacant secretary position is also recommended, not as a fix for the root cause but because the contributing factor is real.

Each action has a measure attached so the team will know whether it worked: the proportion of critical results acknowledged by the responsible nurse or physician within 30 minutes, drawn from laboratory and electronic record timestamps, and the number of critical potassium results with no documented clinical response within an hour. The team will report both measures monthly to the hospital's patient safety committee for a year, and the analysis will be shared, with identifying details removed, at a unit staff meeting so that the people closest to the event hear that the findings concerned the system rather than them.

Conclusion

A potassium of 6.9 mmol/L went unacted on for three hours not because anyone was careless but because the hospital's defenses had holes that lined up at shift change: a notification process that accepted any listener, an electronic record with no alert, a stretched unit secretary and continued medications no one was prompted to review. Tracing the event to those system conditions, and distinguishing root causes from contributing factors, points to actions strong enough to prevent the next result from reaching a patient the same way.

References

National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm.

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768

Valenstein, P. N., Wagar, E. A., Stankovic, A. K., Walsh, M. K., & Schneider, F. (2008). Notification of critical results: A College of American Pathologists Q-Probes study of 121 institutions. Archives of Pathology & Laboratory Medicine, 132(12), 1862-1867. https://doi.org/10.5858/132.12.1862