pneumothorax rca case instru guide

7/21/2019 Pneumothorax RCA Case Instru Guide

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Pneumothorax Case and Instructors Guide

NOTE: This teaching case has elements from many real case studies, but many

details were manufactured to ro!ide enough information to accomlish the "C#

Team exercise

Team $embers 1) Radiology resident (not involved in this case)

2) Radiology physician (not involved in this case)

3) Nurse from a similar unit4) Department manager (not radiology, but similar)

E!ent has occurred before most recently on 2!2!""

Corrective actions at that time included# awareness training for residents

on service$ changed rocedure to have follo%up chest &rays done%ithin 2 hrs, unless there %as a change in status

%ummary of the E!ent

' is a **year old male %ho %as found to have a solitary pulmonary nodule in theupper lobe of his right lung detected on a chest &ray, %hich %as ta+en for possible

pneumonia e %as subse-uently seen by a pulmonary medicine consultant %ho advised

a ./ scan guided fine needle biopsy of the lung nodule /he clinic physician and nurse

both informed the patient there %as li+ely to be minor discomfort after the procedure andit %ould not be necessary to stay overnight

' %as admitted to the short stay hospital unit (00) on the morning of 11!1!"" to have

a ./ guided biopsy of the lung nodule by an interventional radiologist 'fter he %asmildly sedated, the patient %as transported to the radiology department /he patient also

had an catheter inserted and cardiac rhythm and blood pressure monitors attached/he interventional radiologist %as assisted by a radiology resident /he role of the

resident %as to learn the techni-ue by assisting %ith the procedure and monitoring the

patient /he ./ scan image %as used to locate the lesion /he radiologist inserted a

needle through the chest %all into the nodule and aspirated tissue for the specimen 'fter the needle %as %ithdra%n both clinicians noticed a small &'()*+ neumothorax (air

inside the chest cavity but outside the Right lung), a common complication /he partially

sedated patient had no complaints and denied any shortness of breath or pleuritic chest pain

'fter a 1*minute delay in transport, the patient %as ta+en bac+ to 00, and monitors%ere reattached n the net 35 minutes, no staff had directly chec+ed on the patient

During that time, the pulse oimeter alarmed 6lo% oygen7 repeatedly, but the patient

began to silence the alarm as he previously had learned to do /he patient %as surprisedthat he had rightsided chest pain %ith inspiration but he did not inform his nurse e had

rationali8ed this pain as a transient problem that %ould soon disappear

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%ummary of the E!ent Pneumothorax &cont-+

9ifteen minutes later, the nurse noticed ' silencing the alarm and grimacing 'fterchec+ing vital signs, vie%ing his pulse oimeter and loo+ing at the chart, she re-uested a

follo%up chest &ray to be done '0': 0he also called the interventional radiologist

lood pressure, heart rate, and respiratory rate %ere all elevated /he radiology notes inthe chart %ere impossible to read, and she remembered that the resident usually dictated

procedure notes

/he chest &ray no% sho%ed a .)* neumothorax ' thoracic surgery resident %as

called, and he inserted a chest tube to reepand the right lung /he chest tube remained

in place for three days due to a persistent air lea+ /he patient %as discharged home 4days after the biopsy procedure

Immediate #ctions:

1) 'n &Ray %as ta+en

2) ' chest tube %as placed3) :atient %as cared for %ith fluids, pain medications, and %atched closely %ith a

cardiac monitor and pulse oimeter

4) /he records +ept in the radiology department %ere copied

*) /he pulse oimeter %as sent to clinical engineering for testing

;) /he 9acility Director %as told about the case on 11!2!"" (24 hours after the event)

Other /seful 0ata:

1) :atients are usually evaluated e!ery . minutes after a procedure %ith continuous pulse oimetry

2) /he pulse oimeter %as found to have no malfunctioning parts

3) /he 00 %as a ne% concept for this ' facility (2 months old)

4) /he patient signed a consent form

2



Instructors Guideboo12 Pneumo Case

3egan each session by doing the following:

(+ dentify that you %ill act as RCA Advisor

4+ 'ssign or confirm %ho is the RCA Team Leader and Recorder/Secretary

5+ <a+e sure each team member has a blan+ RCA Form and Triage Questions out in front

of them

Gradually let the Team 6eader become the 6eader7

(+ =pect that some R.' /eam >eader %ith be reluctant, you need to let themstruggle a bit to sho% ris+ managers that they need to pic+, train, and be ready to

support their team leaders

4+ >et the R.' /eam >eader dra% the flo% charts and lead the team through most

items$ you %ill probably need to prod and guide %ith triggering -uestions

5+ ?hen creating 'ctions and @utcomes, you many need to ta+e the R.' team bac+

to root causes that %ere poorly %orded

8+ D@ N@/ let the /eam stray from the 6+ey7 points listed belo% A

/hey need to address the +ey points first (at least) Bou should help them %rite, or re%rite at least one ro% in /able 1" that is

6correct7

9ey Problems or Issues with Pre!ious Training Teams

(+ /hey might not %ant to dra% an initial flo% chart$ Cumping to root causes or

solutions

4+ /hey might %ant to spend a lot of time dra%ing an overly detailed flo% chart

5+ /hey might not understand %hy the triggering -uestions help

8+ /hey might get distracted by minor or moderate details about the 6medical7 parts of

the case

(?e are attempting to improve the medical details to avoid this)

.+ /hey might focus on the shortcomings of people (blamingtraining), not systems

redesign

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9ey Points to be Co!ered for this Case %tudy

(Bour /eam 0hould 9ocus on /hese tems and /riggering uestions 9irst)

I+ #CT/#6 %#C 4,7 3ut POTENTI#6 %#C 5

/eam could say delay caused increased length of stay moderate /eam could say delay caused permanent lessening of function maCor

II+ ;/$#N <#CTO"%=CO$$/NIC#TION#

;<=C 42> A ?as info from various assessments and diagnostic %or+ups shared,etcE (read all of the first eight -uestions A all apply to one degree or another)

Fey items for -uestions 2G

<issing information on chart

No communication about small pneumothora

:atientHs reluctance to as+ for help or be evaluated Ne% handoffs and communication procedures for ne% 00

III+ E?/IP$ENT: :ulse oimeter and its alarm

E@ ?as the e-uipment designed to properly accomplish its intended purposeI

Yes, but team could question the overall purpose of oimeter being a

!primary" monitor

The team may as# about the sensitivity of settings on the oimeter$

E(@ A ?as the design such that mista+es of use %ould be unli+ely to happen

No, the patient had seen others staff hit silencing the button all the time$E4( A ?as the e-uipment designed so that corrective actions could beaccomplished in a manner that minimi8ed!eliminated any undesirable outcomeI

No, easily accessible silencing s%itch location$

IA+ "ule 8 Each rocedural de!iation must ha!e a receding cause

&<rom <IAE "/6E% O< C#/%#TION+

/='< <J/ 0'B# !nurse did not follo% procedure" (ie, blaming patient or nurse)

Bou %ant them to focus upon N@R<0 9@R '>'R<0 'ND .=.FNJ :'/=N/0#

Discuss %hat might be the ositi!e and negati!e incenti!es that created N@R<0 for#

Not reacting to alarms

Not follo%ing standard procedures for chec+ing patients

4



Issues and #nswers &General+

• ?: ?hy hadnHt the presence of a K15L pneumothora been communicated to the

00 nursing staffI

o #: /he radiology resident %as busy %ith another patient and forgot to call

the 00• ?: ?hy %as the patient not assessed immediately after returning to the 00I

o #: /he patientHs nurse %as busy preparing her other patient for the @R

• ?: ?hy %asnHt the patient educated on the use of the pulse oimeter and told not

to shut off the alarmsI

o #: /he nurse does not have enough time to educate her patients regarding

pulse oimetry

• ?: ?as there a standard procedure for the resident to order a repeat chest &ray

after an initial pneumothora %as discoveredI

o #: Nobut that is the general practice after such a procedure

*



Inter!iew ?uestions=#nswers &related to issues abo!e+:

• Inter!entional "adiologist

o ?: ?hat is the usual procedure for communicating the details of a

procedureHs outcome and complications to the patientHs nurseI

#: Hm not sure there is a standard procedure but usually %rite a

-uic+ note in the chart but the resident generally %rites or dictatesa more etensive procedure note and usually spea+s to the nurse if

a complication occurs that the nurse needs to be a%are of

o ?: n this case %hy %asnHt the pneumothora reported to the nurse so the

patient could be closely monitoredI

#: /he resident usually does follo% up %ith nurse on the floor

after a procedure %here a complication occurso ?: Do you usually order a follo%up chest ray on these types of casesI

#: Beahthe residents +no% they need to do that

• "adiology "esident


procedureHs outcome and complications to the patientHs nurseI

#: usually dictate a procedure note and %rite a note in the chart

f there is something the nurse needs to +no% more urgently give

her a callo ?: n this case %hy %asnHt the pneumothora reported to the nurse so the

patient could be closely monitoredI

#: called up to 00 but the patientHs nurse %as busy so

planned to try again later disli+e leaving messages %ith the

covering nurse ?e had a really busy schedule that day and before

could call her bac+ had heard about %hat had happened frommy attending

o ?: Do you usually order a follo%up chest ray on these types of casesI

#: Beah, al%ays do but that day %as cra8y and Cust didnHt get to

it in time /he team ta+ing care of the patient upstairs usuallycatches that +ind of thing and places the order ?e really %erenHt

%orried about this patient is pneumothora %as small and didnHt

seem to be a problem

;



• %%/ Nurse


procedureHs outcome and complications to youI #: usually Cust read the notes in the chart and %ait for the

dictation from the resident because it is much easier to read fthere %as a problem %ith the procedure they are supposed to let me

+no%

o ?: ?hy did it ta+e so long for the patient to get assessed once he got bac+

to the 00I

#: Hm really pretty good about chec+ing in %ith them as soon as

they get bac+ from a procedure /hat day %as busy preparing

another patient for the @R %hen the patient got bac+ /he nurse

that %as covering %as one of those agency nurses and reallydoesnHt +no% her %ay around yet 0he Cust didnHt get to chec+ on

him after the procedure because she %as busy %ith another patient

M

pneumothorax rca case instru guide

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