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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 accomlish 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 unit 4) Department manager (not radiology, but similar)

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

Corrective actions at that time included# 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 the upper 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 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 and it %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 the lung nodule by an interventional radiologist radiologist 'fter he %as mildly sedated, the patient %as transported to the radiology radiology department /he patient also had an  catheter inserted and cardiac c ardiac rhythm and blood pressure monitors attached /he interventional radiologist %as assisted by a radiology 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 into the nodule and aspirated tissue for 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 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 reattached n the net 35 minutes, no staff had directly chec+ed on the patient During that time, the pulse oimeter alarmed 6lo% 6 lo% oygen7 repeatedly, but the patient  began to silence the alarm as he previously had learned to do /he patient %as surprised that he had rightsided chest pain %ith inspiration but he did not inform his nurse e had rationali8ed this pain as a transient problem that %ould soon disappear


%ummary of the E!ent  Pneumothorax &cont-+ 9ifteen minutes later, the nurse noticed ' silencing the alarm and grimacing 'fter chec+ing vital signs, vie%ing his pulse oimeter a nd 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 in the 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 reepand the right lung /he chest tube remained in place for three days due to a persistent air lea+ /he patient %as discharged home 4 days after the biopsy procedure

Immediate #ctions: 1) 'n &Ray %as ta+en 2) ' chest tube %as placed 3) :atient %as cared for %ith  fluids, pain medications, and %atched closely %ith a cardiac monitor and pulse oimeter 4) /he records +ept in the radiology department %ere copied *) /he pulse oimeter %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 oimetry 2) /he pulse oimeter %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


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 them struggle 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+ [email protected] [email protected]/ 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 (blamingtraining), not systems redesign


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 2G  <issing information on chart  No communication about small pneumothora  :atientHs reluctance to as+ for help or be evaluated  Ne% handoffs and communication procedures for ne% 00

III+ E?/IP$ENT: :ulse oimeter and its alarm [email protected]  ?as the e-uipment designed to properly accomplish its intended purposeI Yes, but team could question the overall purpose of oimeter being a !primary" monitor  The team may as# about the sensitivity of settings on the oimeter$ 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 b utton all the time$ E4( A ?as the e-uipment designed so that corrective actions could be accomplished 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" (ie, blaming patient or nurse) Bou %ant them to focus upon  [email protected]<0 [email protected] '>'R<0 'ND .=.FNJ :'/=N/0# Discuss %hat might be the ositi!e and negati!e incenti!es  that created [email protected]<0 for#  Not reacting to alarms  Not follo%ing standard procedures for chec+ing patients


Issues and #nswers &General+ •

?: ?hy hadnHt the presence of a K15L pneumothora been communicated to the 00 nursing staffI o

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

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

?: ?hy %asnHt the patient educated on the use of the pulse oimeter and told not to shut off the alarmsI o

#: /he radiology resident %as busy %ith another patient and forgot to call the 00

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

?: ?as there a standard procedure for the resident to order a repeat chest &ray after an initial pneumothora %as discoveredI o

#: Nobut 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 


?: 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 occurs

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

#: Hm not sure there is a standard procedure but usually  %rite a -uic+ note in the chart but the resident generally %rites or dictates a more etensive procedure note and usually spea+s to the nurse if a complication occurs that the nurse needs to be a%are of

#: Beahthe residents +no% they need to do that

"adiology "esident o

?: ?hat is the usual procedure for communicating the details of a  procedureHs outcome and complications to the patientHs nurseI 


?: n this case %hy %asnHt the pneumothora reported to the nurse so the  patient could be closely monitoredI 


#:  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 call

#:  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 from my attending

?: 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 usually catches 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 o

?: ?hat is the usual procedure for communicating the details of a  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 f there %as a problem %ith the procedure they are supposed to let me +no%

?: ?hy did it ta+e so long for the patient to get assessed once he got bac+  to the 00I 

#: 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 really doesnHt +no% her %ay around yet 0he Cust didnHt get to chec+ on him after the procedure because she %as busy %ith another patient


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