Root Cause Analysis Simulation: Internal Medicine Resident (PGY2)

Frame of Mind for the RCA: You were interviewed by the safety officer yesterday regarding this case. You are really worried about the impact this will have on your evaluation as a resident. Your attending was very angry that you had not reported the issue to him.

You really like working with this nurse, she has always had your back, but you feel you had to ‘write up’ the nurse with a safety event report because she made such a significant mistake.

Your perception of the event: You recall inserting a PICC line in this patient on the night of the event. You got a chest x-ray to ensure the PICC line was in the correct position. You viewed the film and noticed the line was a bit too far in, so you pulled it back about 4 cm and ordered a repeat film. You reviewed the film and were satisfied with the position of the line. You ordered these x-rays as ‘routine’ because you intended to view the films yourself.

The next night you received a call from the patient’s nurse that the O2 sats were now in the 60’s with wheezing. You stopped the tube feedings and ordered another chest x-ray (routine). You didn’t hear anything back from the night nurse. In the morning you stuck around for grand rounds. You received a call from the Attending Radiologist who was very upset with you for not stopping the tube feedings the night before last. The Radiologist informed you that the radiology report from 2 nights ago showed ‘a complete opacification of the right hemithorax.’ He said the NG tube was in the lung.

You went back to review the patient’s record.

You read, for the first time, the radiologists report from the routine x-rays that you ordered 2 nights ago to verify, and then re-verify, the PICC placement. You realized that you had never gone back and read the final report from radiology, which indicated that while the PICC was positioned correctly, the NG tube was ‘projecting towards the right upper abdomen’.

The second radiology report indicated that the NG tube was in the right mainstem bronchus, and that the radiologist had ‘already notified the service’. How could that be? You were never told!