“The only real mistake is the one from which we learn nothing.”
- John Powell
The Cyanotic Child
Systems Failures in the Emergency Department
Systems Failures in the Emergency Department
In MacDonald v. Chestnut Hill Hospital, 903 A.2d 61, 2006 Pa. Super. LEXIS 2061 (Pa Super. Ct. June 1, 2006), a family alleged multiple systems failures in the treatment of their newborn baby girl.
On October 25, 2000, Erin MacDonald was born without complication at Chestnut Hill Hospital. The parties dispute whether the baby was feeding properly and whether she was overly sleepy, but everyone agreed she appeared outwardly healthy. She was discharged two days later from the hospital. While at home, Erin had a brief cyanotic episode. Mom called 911 and Erin was transported back to the hospital’s Emergency Department. Ambulance workers noted that Erin’s color was normal and she appeared stable. In the Emergency Department, Erin’s temperature, blood pressure, and respirations were normal, and her condition also appeared stable to the attending physician. Due to her cyanotic episode, however, the attending physician felt that Erin should be admitted.
Arrangements were made with Erin’s pediatrician to transfer her to another hospital with a pediatric floor. Erin’s temperature at the new hospital was 100.9 degrees on arrival. The physicians were concerned that Erin was septic. Labs drawn at the new hospital revealed that Erin was in fact hypoglycemic. A “heel stick” confirmed hypoglycemia and a dextrose infusion was begun. During treatment, she had multiple seizures and suffered permanent brain damage. Erin was eventually diagnosed with congenital hyperinsulinism.
One of the many allegations of the MacDonald family was that if a “heel stick” had been initially performed in the Emergency Department, Erin’s glucose would have been controlled more quickly, thus preventing subsequent seizures and brain damage. An expert witness testified that the hospital had protocols for obtaining a “heel stick” which were not followed by the medical staff. In the end, however, the jury found in favor of the physicians despite evidence of negligence, because the negligence was not the cause of the harm suffered.
If Erin did not have congenital hyperinsulinism, the jury could have easily found in favor of the MacDonalds. In such a circumstance, the jury may have agreed that Erin’s hypoglycemia could have been more quickly diagnosed and more easily controlled, thus avoiding brain damage from seizures.
A fingerstick is often thought of as the sixth vital sign. It is well-recognized that altered mental status or neurologic deficits are often the result of hypoglycemia, and can be completely reversed with prompt administration of dextrose. It is for this reason that the hospital had protocols in place for performing “heel sticks,” and the staff, if speaking candidly, would probably agree that a “heel stick” would have been appropriate even in the above case. Furthermore, obtaining one drop of blood from a “heelstick” has almost no risk of an adverse consequence.
So why did the system fail? Was there a lack of automaticity to the system? Did the system rely on the staff to make a decision for a simple diagnostic intervention that should have been thoughtless?It is hard to believe that a physician or nurse would have actively decided that Erin did not require a fingerstick for her cyanotic episode. It was most likely a simple failure to think of the intervention.
Whatever the source of error, systems should be designed not to eliminate human error, but embrace it. A system should anticipate human error, as in the above case, and insure implementation of simple interventions in well-defined situations. For instance, checking vital signs on every patient entering the Emergency Department, regardless of chief complaint, is one of our most basic systems for preventing patients with serious illness from being missed. At times, the system should cast a larger net than the individual medical decision-maker to prevent missing common diagnoses. The system cannot make all of the decisions for medical staff, but perhaps the true decision-making component of medical care should be left to those problems that are more difficult to solve.
Dainius A. Drukteinis, M.D., J.D. is a fourth year Emergency Medicine Resident at NYU/Bellevue Hospital and author of Law and Medicine Rounds. He may be contacted at firstname.lastname@example.org