Incorrect Consent for a Chest Tube Insertion

By Alexis Reeves, RN, CPHRM, CLNC, Director of Patient Safety Operations & Implementation

Incorrect Consent for a Chest Tube Insertion
Providing safe patient care relies heavily on an organization’s ability to learn from near misses and adverse events. Learning organizations openly share these challenges, as well as their successes, to help prevent errors from recurring. That is the purpose of this column—to provide transparent information to physicians and staff about the important information gleaned from root cause analyses (RCA) and other investigations. Lessons Learned will share the real stories of near misses and adverse events that have occurred at SHC to illustrate how system failures can lead to human error and to highlight how improved processes can decrease the likelihood of errors. Our goal in all of this is to openly share organizational learnings to continually improve patient care.

Event
A 75-year-old male patient presented to the Emergency Department (ED) with weakness, dyspnea, worsening anemia and left pleural effusion requiring thoracentesis. The patient previously had a CT exam at an outside clinic, which showed left greater than right pleural effusion. When he presented to Stanford 10 days after this CT scan, a thoracic surgery resident came to the ED to evaluate the left pleural effusion. The resident reviewed the chest x-ray with the attending physician before consenting the patient for a chest tube. However, the patient was incorrectly consented for a right chest tube. Before the chest tube insertion, the care team conducted a time-out. While the resident was making the initial incision, the pulmonary physician arrived and stated that the pleural effusion was on the left side. The resident sutured the superficial incision; the patient was notified and was agreeable to left chest tube insertion. Although the wrong-side insertion of the chest tube did not occur, this event prompted a Root Cause Analysis to uncover any system failures, and to identify how to prevent such events in the future.

Gaps Identified

• Lack of standardized process for Verification/Time-out for invasive procedures occurring at the bedside
• Chest x-ray image was not available at the time of the Time-out. The computer was being used by another provider.
• Site marking was not part of the process for chest-tube insertions
• Patient presented with bilateral pleural effusions, causing confusion. The right-sided pleural effusion did not warrant a chest tube.

Actions to Prevent Future Similar Events

• Standardize the Verification/Time-out process for invasive procedures that occur at the bedside.
• Make the computer accessible and available to physicians during the consent process.
• Educate physicians and staff regarding the required site-marking process for all invasive procedures to assure that the site(s) is marked before beginning the procedure.
• Ensure involvement of all staff participating in the invasive procedure in the Verification/Time-out process.

Health care is a complex system with many moving parts. Since humans are necessary in providing care, we must do all we can to improve the system to support our dedicated physicians and staff. We must not blame the individual, but rather the system that failed to provide the necessary fail-safes. As a learning organization, Stanford Health Care will continually search for opportunities that lead to a safer environment for our patients, physicians and staff.