Medical Error
Case Study of Human Cognition - Fall 2018
Abstract
This study examines a fatal medical error that took place at Saint Mary’s Hospital Medical Center (SMHMC) on July 5, 2006. First, this study identifies the key events that resulted in the death of the patient and relate the causes with human cognition theories. Then, this study proposes ten solutions that could address the human limitations and enhance performance. The takeaway of this case study is that healthcare systems should be dedicated to facilitating the medical staffs’ cognitive processes so that hospitals could become a safer place.
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Note: Some details and explanations aren't shown on this page. For more detailed information, please refer to the project report located at the bottom of this page.
The Event
Overview
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Date: July 5, 2006
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Place: St. Mary’s Hospital, a 440-bed community teaching hospital in Madison, Wisconsin
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Jasmine Gant: a 16-year-old pregnant girl
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Julie Thao: the registered nurse who made the medical error
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The medical error: wrong drug was infused through a wrong route
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Result: The girl died. The nurse was charged with a felony criminal offense. Restrictions on the nurse’s ability to participate in healthcare programs were imposed. The nurse’s license was suspended for nine months, and the hospital terminated her employment.
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Timeline
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9:30 a.m., Jasmine Gant came to St. Mary’s Hospital. She was three hours late for her scheduled induction.
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The nurse completed the admission profile, but didn’t apply a bar-coded ID band to Gant’s arm.
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In the following two hours, the nurse discussed and explored family dynamics with Gant and her mother. During this timeframe, the patient reportedly expressed a desire for epidural pain management during labor.
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11:30 a.m., the physician began the induction process.
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The nurse mentioned epidural pain management to the physician.
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The nurse brought Lactated Ringer’s solution, Pitocin, delivery kit medications, and a bag of epidural solution from the automated dispensing cabinet (ADC) to Gant’s room.
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Another nurse placed a penicillin bag on the counter and shouted: “your penicillin is here on the counter!”
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Gant started to cry and was in a panic.
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The nurse began the infusion without looking at the medication bag carefully. She failed to check “the five rights of medication administration”, and she planned to scan the infusion bag later.
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Within five minutes, Gant’s condition became serious.
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The medical team thought the symptoms were the allergic reactions to penicillin.
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Resuscitation didn’t work.
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Gant was emergently moved to a birth suite operating room. By emergency cesarean, the baby was delivered safely.
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The resuscitation continued for 80 minutes, but was still not working.
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1:43 p.m., the medical team stopped the resuscitation.
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After a while, a partially infused epidural bag and an unused penicillin bag was found.​
Key Events & Associated Causes
1. The nurse didn’t apply a bar-coded ID band to Gant’s arm.
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Similar to the “effort” in SEEV model: ID bracelet was too far.
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The adaption (abandon lower-priority tasks) because of the high workload.
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Prior tolerance + previous experiences + familiarity with the patient = The nurse considered this action low risk
2. The nurse retrieved an epidural bag before it was prescribed.
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Stress: Caused by Gant’s nervousness and anesthesiology staff.
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The adaption (perform tasks in a more efficient way) because of the high workload.
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Poor communication with anesthesiology staffs + anticipation + past practice by several nurses = The nurse considered this action low risk
3. The nurse didn’t scan the bar code on the infusion bag.
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Not rehearsed enough: The scanning system was a recent implementation
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Scanning problems & no ID band to initiate the process
4. The nurse picked up the wrong drug and didn’t notice it was epidural.
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Fatigue
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Tired brain = drunk brain: Didn’t remember to check “the five rights”
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Decreased vigilance (routine medication): Miss the signal from the label.
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Inattentional blindness: Looked, but failed to see the hot pink warning labels.
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(Note: The nurse was fatigued on the day of the event. The day before, she had worked for two consecutive eight-hour shifts and then slept in the hospital before coming on duty again the following morning. - from Shaping Systems for Better Behavioral Choices: Lessons Learned from a Fatal Medication Error)
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Stress
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Trade-off between speed and accuracy in visual search: The nurse was in a rush.
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Limited attention resource: auditory attention (Gant was crying) decrease the nurse’s attention resource for visual attention
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Confirmation bias: Similar appearance and compatible tube supported the nurse hypothesis that the bag was penicillin.
The epidural and penicillin medications were in the same-size containers, and both had orange pharmacy-applied labels; the pink warning labels on the epidural bag helped to differentiate the products but were overlooked.
5. The medical team thought the symptoms were allergic reactions to penicillin.
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Change blindness: humans are relatively poor at noticing the unexpected.
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The “Expectancy” (in the SEEV Model) of infusing the wrong drug was low.
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Low situation awareness.
6. The partially infused epidural bag and the unused penicillin bag weren’t noticed until Gant’s death.
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Selective attention: The “flashlight beam” was illuminating the patient, so the infusion bag on the counter couldn’t be noticed.
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Focused attention: The medical team was focused on the resuscitation. The “flashlight beam” was narrow.
Possible Solutions
1. Deliver the ID band to the patient’s room as soon as possible.
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Reduce the "effort" (in the SEEV model) to get the ID band.
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2. Assign additional nurses to help.
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Reduce the difficulty of the nurse’s task.
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Lower the workload and thus prevent adaptions.
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3. Assign specialists to soothe anxious patients.
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More unused attention resource to notice the crucial elements.
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Reduce the stress caused by the patients.
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4. Facilitate communication and collaboration between medical members.
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Reduce the stress caused by the dissatisfaction of anesthesiology staff.
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5. Solve the scanning problems and arrange adequate rehearsing of the scanning process.
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Help nurses keep the scanning process in mind.
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6. Make the warning label more salient.
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Address the decreased vigilance due to fatigue and familiarity with the routine drug.
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7. Cover a warning label over the connection point.
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Ensure that the nurses would encounter the warning before infusing the medication.
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8. Make the appearance of epidural bag unique and use an incompatible connection point to intravenous tubing.
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Help address inattentional blindness.
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Block the confirmation bias.
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9. Prohibit the nurses from taking consecutive long shifts.
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Reduce fatigue.
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10. Educate medical teams to be more aware of their surroundings.
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Raise situation awareness.
Conclusions
Human cognition plays a big role in the healthcare environment. If the cognitive limitations aren’t treated properly, medical staff are prone to make medical errors. In this case study, we can see that there were many defects in the healthcare system that added cognitive difficulties to the nurse. Therefore, it is essential for the healthcare systems to make more efforts on facilitating the medical staff’s cognitive processes, so that the healthcare systems could become a safer place for patients, and also a friendlier working environment for the staff.