By Elia Petzierides
“Lots of little things done well” is chef Marco Pierre White’s recipe for perfection, and the same definition could equally apply to the healthcare setting. But as we discover in this GraveLesson, perfection isn’t always achieved in healthcare. Soon after 74-year-old Mrs Marcia Loveday presented to hospital, lots of little things (and some not so little) went wrong and she was administered a penicillin based antibiotic despite her known and recorded allergy to penicillin. She suffered a cardiac arrest moments later. How did this happen and what can be done to prevent this from happening again?
Mrs Loveday enjoyed a good level of health and lived with her husband in Queensland, Australia. She had a medical history of diabetes, glaucoma and asthma. Notably, Mrs Loveday had an allergy to penicillin which she had known about for 20 years and diligently wore a MedicAlert bracelet to alert health professionals to her life-threatening condition.
On Friday July 16, 2010 Mrs Loveday saw her general practitioner for chest and abdominal pain as well as a cough for which she was prescribed an antibiotic (Clarithromicin) and sent home. The pain continued over the weekend and on Monday morning she was experiencing trouble breathing in addition to the chest and abdominal pain.
An ambulance was called and she was found to be in severe respiratory distress – she was only able to speak single words between her rapid breaths. In addition to managing Mrs Loveday’s respiratory distress and pain the intensive care paramedics ascertained Mrs Loveday’s allergy to penicillin, ceclor, minomycin and keflex, handed these over to the triage nurse at the hospital, documented them in their clinical notes and left a copy with the hospital staff. The triage nurse documented allergies to ceclor, minamycin and keflex. The triage area was described as merely an area in the hallway and in the words of the triage nurse was “extremely busy” and “chaotic” on this particular morning.
At the time of arrival at triage there were two other ambulances waiting to see the triage nurse and Mrs Loveday’s paramedics ‘jumped’ the queue given her time critical nature. This is not frowned upon as patients are to be triaged in order of priority, not order of arrival.
After being triaged, in light of the severity of her respiratory distress Mrs Loveday was given an Australasian Triage Score Category 2 (to be seen by a doctor within 10 minutes) and taken to the resuscitation area by the paramedics where she was handed over to nursing staff. Medical staff entered part-way through the handover. Due to a system glitch the triage notes failed to arrive in the resuscitation room and Mrs Loveday’s hospital file – complete with an alert flag for her allergies – did not arrive in the department within the 10 minute time frame required for Category 2 patients. The space for allergies on the clinical notes in the resuscitation room remained blank.
An urgent portable chest xray was taken and an initial diagnosis of infective exacerbation of Chronic Obstructive Pulmonary Disease (COPD) was made. An intravenous cannula was inserted, bloods were taken for analysis and a bolus of intravenous Normal Saline was prescribed and administered along with a steroid (hydrocortisone) and intavenous Ampicillin (a penicillin based antibiotic). Her conscious state was documented as a Glasgow Coma Scale score of 15 (out of 15) which means she was fully conscious.
Some 30 minutes after Mrs Loveday’s arrival in the resuscitation room and only moments after the intravenous Ampicillin was administered Mrs Loveday went into asystolic cardiac arrest (her heart stopped beating and there was no electrical activity in the heart, depicted as a flat line on an electrocardiograph or ECG). Resuscitation was commenced. During this resuscitation Mrs Loveday’s MedicAlert bracelet was noticed by nursing staff. It listed the following allergies: “PENICILLIN, MINOMYCIN & CECLOR”.
The possibility of an anaphylactic reaction (severe allergic reaction) was considered by the treating doctors however they thought it was unlikely due to the absence of ‘clinical evidence’ – no rash and no facial or airway swelling. Nonetheless, Adrenaline 0.5mg was administered intramuscularly (into a muscle) for treatment of anaphylaxis.
After six minutes of cardiopulmonary resuscitation and approximately one minute after the adrenaline Mrs Loveday had a return of spontaneous circulation (her heart started beating again). She was transferred to the Intensive Care Unit (ICU) where she was given the diagnoses of myocardial infarction, ? sepsis, +/- anaphylaxis. She never regained consciousness and died on her fourth day in ICU.
Autopsies usually provide clarity about the cause of death, however on this occasion it generated a level of uncertainty. The causes of death were listed as:
- Cardio-renal failure due to gangrene (decomposition) of calculous gall bladder.
- Hypertensive and ischaemic heart disease, diabetes mellitus and possible anaphylactic reaction.
The gangrenous gall bladder was deemed to be the source of Mrs Loveday’s abdominal and chest pain. The forensic pathologist was unable to confirm anaphylaxis but was also unable to rule it out. It was this uncertainty that lead to an Inquest being refused by the Coroner but the decision was later overturned after an appeal by Mrs Loveday’s family. An inquest was held with a new Coroner (as is the usual process).
The Inquest set about answering the following questions:
Did Mrs Loveday have an anaphylactic reaction to the Ampicillin and if so, did it result in her cardiac arrest?
The treating doctors’ statements displayed some doubt as to whether Mrs Loveday actually had an anaphylactic reaction. The independent medical experts however had no such doubt. In their opinion Mrs Loveday did indeed have an anaphylactic reaction manifested as anaphylactic shock. One independent medical expert described the reaction as “a typical contemporaneous response to the intravenous exposure to an agent to which a patient is known to be allergic.”
Did the cardiac arrest hasten or accelerate Mrs Loveday’s death?
It was agreed by the independent medical experts that Mrs Loveday would ‘almost certainly’ have died from her gangrenous gall bladder. It was believed that due to the prompt administration of adrenaline that the effect of the anaphylaxis had passed and therefore did not hasten or contribute to her death.
What went wrong?
A summary of the things that went wrong as detailed by the Coroner is listed below:
- Triage area was not ideal for triage – noisy, chaotic and clerk was not working alongside triage nurse.
- Triage nurse did not document all four allergies.
- Triage notes did not accompany patient into resuscitation area.
- Patient history file was not retrieved from history storage area within the required time frame of 10 minutes for a Category 2 patient.
- There was no obligation for anyone to identify and act upon the alert flag for allergies attached to patient history files.
- Resuscitation notes did not list any allergies.
- Doctor who prescribed Ampicillin failed to check for patient allergies.
- Nurse who administered Ampicillin failed to check for patient allergies.
- Doctor, nurse and paramedics failed to identify the patient’s MedicAlert bracelet prior to administration of Ampicillin.
- Treating doctors unaware of possibility of anaphylaxis without cutaneous (skin) effects.
It is worth noting that neither the family nor the independent medical experts called for any referral against any person or entity and the Coroner elected not to make any such referrals.
Will it happen again?
The Coroner felt this incident provided an opportunity to recommend important improvements to protect patients in similar situations and made four recommendations.
Recommendation 1 – MedicAlert bracelets
Given that the MedicAlert bracelet was not seen until after the Ampicillin was administered – the Coroner was alarmed the paramedics did not notice it after spending around one hour with Mrs Loveday – the Coroner spent some time looking at the design and appearance of MedicAlert bracelets. After viewing the bracelet worn by Mrs Loveday the Coroner deemed that the bracelet was likely to have been mistaken for a piece of jewellery or a fashion accessory rather than achieving its primary role of being a method of ‘alerting’ health workers to its presence.
The Coroner was also informed by one of the independent medical experts that junior medical and nursing staff do not recognise or routinely look for MedicAlert bracelets. In light of this ‘low recognition factor’ the Coroner made a recommendation aimed at manufacturers, retailers and promoters of medical alert products recommending they only make available those items which place function over fashion, bear a distinct medical symbol, with prominent durable wording.
Short of formally making a recommendation the Coroner “encouraged” Queensland Health to educate and remind clinicians to be aware of and look for the various medical information products which may be worn by patients.
Recommendation 2 – Anaphylaxis education
The Coroner observed that even the most experienced practitioners were unaware cutaneous (skin) features (such as airway and facial swelling and rash), usually associated with anaphylaxis, may not be present in a patient suffering an anaphylactic reaction. This prompted a recommendation for Queensland Health and Queensland Ambulance Service to educate their front line staff about this possibility.
Recommendation 3 – Triage layout, records retrieval and alert/flag issues
In acknowledging the hospital had already sufficiently addressed these issues the Coroner still felt it prudent to recommend that Queensland Health conduct an audit to identify any hospitals with similarities to the triage layout, records retrieval and alert/flag systems of the hospital in question on the day of Mrs Loveday’s presentation and implement any necessary changes.
Recommendation 4 – Red ‘alert’ wrist band
The Inquest briefly canvassed whether first responder medical personnel (paramedics and emergency department triage nurses) should place a bright red ‘alert’ wrist band clearly branded with ‘ALERT’ on the patient as soon as they identify a patient with a significant condition such as an allergy. The Coroner was of the belief that these would immediately cause a clinician to stop and enquire as to what the alert related to. If one of these had been applied by paramedics it would very likely have caused the prescribing doctor or administering nurse to stop in their tracks after Mrs Loveday’s allergies had clearly failed to be passed along the chain.
Despite having insufficient information to make a formal recommendation the Coroner could not see how such a simple intervention could be difficult or expensive to administer. As such he recommended Queensland Ambulance Service and Queensland Health consult, investigate and if appropriate devise policy to implement a red ‘alert’ wristband system.
Almost two years after this recommendation was made, red ‘alert’ wrist bands are not being applied by paramedics in Queensland. It is not known if Queensland Ambulance Service decided against the implementation or is yet to implement them.
In conclusion, healthcare is a team sport and it is up to every player to deliver their best performance by doing everything, including all of the little things, well. While perfection may be an impossible target to achieve, healthcare providers should be mindful of this and proactively ensure their systems and processes are robust enough to cope with minor glitches and still keep patients safe from errors of this magnitude.
The author Elia Petzierides is a Victorian based Advanced Life Support Paramedic and Registered Nurse with a Graduate Diploma in Advanced Clinical Nursing.
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