JUST CULTURE

The Science of Safety & The Principles of Error Management

CASE
SCENARIOS

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JUST CULTURE
The Science of Safety & The Principles of Error Management

Scenario No. 1
The Faulty Oxygen Cylinder

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Scenario No. 1: THE “FAULTY” OXYGEN CYLINDER

Yesterday, Mr. Albert was admitted to an acute medical ward. He had
been deteriorating over a few hours, raising concern his liver disease was
progressing to multi-organ failure. An urgent transfer to the intensive care
unit (ICU) was arranged. At the point this decision was made he was very
ill, but conscious: with a pulse of 120; BP 92/56; respirations 28, and
saturation of 89% on 15 liters per minute of oxygen.

The porter Mr. Brian brought a patient trolley to the ward and the ward
team helped transfer Mr. Albert from his bed to the trolley. Staff Nurse
Emily and Dr. Smith escorted Mr. Albert to the ICU, which is at the opposite
end of the hospital and down three floors in the lift.

Mr. Albert’s condition worsened considerably about halfway through this

journey. He was cyanosed, had a rapid and faint pulse and agonal
breathing. Nurse Emily and Dr Smith realized that although 15 liters per
minute of oxygen should be flowing from the oxygen cylinder on the trolley
to the oxygen mask Mr. Albert was wearing, there was no flow. The
cylinder was clearly at green so it had not run empty. Nurse Emily said it
was definitely working when they left the ward as she could distinctly
remember hearing a hiss when she turned the flowmeter dial to 15 liters.
Nurse Emily and Dr Smith in turn tried to get the cylinder to work, but
without success, and they concluded the cylinder must be faulty.

Nurse Emily suggested they stop at the nearest ward to use its wall oxygen
and began to turn the trolley. However, Dr Smith overruled her and
shouted at Mr. Brian to push on to the ICU as fast as he
could.

Mr. Albert was close to having a cardiac arrest on arrival

at the ICU about four minutes later, but was stabilized by
the ICU team. He died three days later. His death was
reported to the quality management, as although his
condition was critical even before the oxygen supply was
lost, this event would have reduced his chances of
survival.

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SCENARIO 1: The “Faulty” Oxygen Cylinder

INVESTIGATION
The investigation team collected the key facts, including:

• The technician who examined the cylinder found it was almost full and in
good working order but had not been properly turned on. He explained that
for oxygen to flow a plastic cap needed to be removed and an on/off valve
turned, in addition to turning the flow dial to the correct flow rate (in this case
15 liters per minute). If the valve is not opened a brief hiss of oxygen may still
be heard but there is no further flow of oxygen. The plastic cap was still in
place on this cylinder and the valve was closed.

• Mr. Brian said he had been a porter for five years and had been taught to
check and prepare oxygen cylinders each time he collects a trolley. About six
months ago the porters were told by their supervisor not to turn oxygen
cylinders on as this was a clinical task. Although he knew how to turn the
cylinders on, he said that when problems arose on Mr. Albert’s journey he had
assumed that if Nurse Emily and Dr Smith said the cylinder was faulty, then it
must be faulty. He therefore just concentrated on pushing the trolley to ICU as
fast as he could.

• Nurse Emily said she had 20 years of medical ward experience but was used
to relying on the porters to bring trolleys complete with an oxygen cylinder
ready for use. She had not had any training in using these cylinders and was
not aware of any change in policy. She had turned cylinders on in
emergencies in the past but those cylinders had a simpler design. She said she
had genuinely believed oxygen was flowing when Mr. Albert left the ward
and could not understand why it was not mid route. She said that after the
incident she looked up the instructions for these cylinders on the internet.
While she considers herself to be technically adept, it took her a few minutes
to understand how to turn them on properly using the numbered diagrams
provided by the manufacturer.

• Nurse Emily said that when they were half way to the ICU and
unable to get the oxygen cylinder working, she thought the
priority was to get Mr. Albert to a working oxygen supply as the
patient’s color was so poor and his breathing so close to
respiratory arrest. However, she knew that the worst of all
responses was to play ‘tug of war’ over the trolley. So, when
Dr Smith insisted on pressing on, Nurse Emily thought it was best
not to waste more time by disagreeing.

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SCENARIO 1: The “Faulty” Oxygen Cylinder

INVESTIGATION
• Nurse Emily’s ward manager, Ms. Paula, said she did recall receiving an email
about the shift of responsibility for turning oxygen cylinders on. She assumed,
however, that there would be some kind of central training program and did
not realize she was meant to submit the names of nursing staff who needed to
be trained. The investigation team agreed this email, sent on behalf of the
chair of the medical gases committee, was not as clear as it could have
been.

• Dr Smith said she was at the start of her second foundation year (FY2) and
had never been trained in how to turn on oxygen cylinders, nor did she realize
she needed to be. She assumed porters or nurses should know what to do.
When she checked the cylinder mid route she could not see anything wrong
with it but there was clearly nothing coming out either. She agreed she
shouted at the porter to keep going when Nurse Emily began to turn the
trolley to a nearby ward. She said she decided it was best to press on to ICU
because she thought Mr. Albert was deteriorating fast and she would not be
able to do much for him if they diverted to a ward. She added she knew how
important it is to be decisive in emergencies and had talked her decision over
with some close FY2 friends; they all agreed she did the right thing.

• Professor Philip was the consultant leading the team Dr Smith works in. He said
if it had been him with a cyanosed patient midway to ICU and an apparently
faulty oxygen cylinder, he would probably have stopped off at the nearest
ward to get the patient back on oxygen before they went into full arrest.
However, he agreed it was not an easy decision to make.

• Dr David, the chair of the medical gases committee, said they switched to this
cylinder design three years ago as it reduced the risk of cylinders being
unintentionally left on. This reduced the risk of them being empty when
needed or creating a fire hazard. Responsibility for turning cylinders on
switched from porters to nurses about six months ago, to
reinforce the message that oxygen needs to be prescribed
rather than just given. The committee had not been monitoring
take up of training but after this event it identified that only 22%
of nurses had attended the local ‘using oxygen cylinders safely’
sessions.

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JUST CULTURE
The Science of Safety & The Principles of Error Management

Scenario No. 2
The Missing Pethidine

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Scenario No. 2: THE MISSING PETHIDINE

Three new mothers complained about having had a very painful labour.

The investigation team suspected Midwife Greta Green had been injecting women in
labour with ‘water for injection’ and keeping the pethidine they were prescribed for
her own use.

Midwife Green admitted she has been doing this for some weeks as she had become
addicted to opiates after her GP prescribed them for pain stemming from an earlier
back injury sustained at work. She says that when her GP reduced her prescription she
turned to the painkillers she could access at work. She said she was glad she has
been found out. She was feeling very guilty knowing that the pain and distress these
women went through each time she did this was her fault.

The investigation team found Midwife Green had been able to steal pethidine
repeatedly because in the busy community midwifery unit it had become normal
practice for midwives to bring prepared doses of pethidine into each other’s labour
rooms for checking and signing the controlled drugs register. In practice, midwives in
the unit rarely observed each other injecting pethidine.

Three other midwives on the unit (Midwives Thomson, Scott and Wilson) had
countersigned doses of pethidine prepared by Midwife Green but acknowledged
they did not see her give the injections. The midwives said they were ‘caught’
between two policies. One of those policies states that they should not leave the side
of the woman they were looking after if she was in active labour.
They thought that policy was more important than
the controlled drug policy that required them to
accompany their colleague to observe the
pethidine being given. With hindsight it appeared
Midwife Green had picked times when she knew
her colleague would not want to leave the woman
they were caring for.

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The Science of Safety & The Principles of Error Management

Scenario No. 3
Nasogastric Tube Placement Check

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Scenario No. 3: NASOGASTRIC TUBE PLACEMENT CHECKS

Mrs. Tracey was recovering from a stroke on an acute stroke ward. She
was unable to swallow safely.

Nurse Jones inserted a nasogastric (NG) tube around midday but could
not obtain pH within the safe range. In line with hospital policy he
requested an X-ray to confirm the tube was correctly placed in the
stomach before using it.

Mrs. Tracey had the X-ray taken and returned to the ward about 4 pm.

Dr. Abdullah who was on the ward to see another patient, checked the
X-ray. He confirmed in Mrs. Tracey’s notes that the tube was correctly
placed and safe to use for feeding.

Nurse Jones started a feeding regime via the NG tube at about 4.30 pm.
An hour or so later her condition generally deteriorated. The FY2 doctor
covering the medical wards that evening reviewed Mrs. Tracey. She
suspected pneumonia and checked the recent X-ray for signs of this. It
was immediately obvious to her that the NG tube was placed in the right
lung. The feed was stopped and Mrs. Tracey was transferred to ICU for
treatment of the effects of the liquid feed introduced into her lung. Mrs.
Tracey was still in intensive care and critically ill as the investigation started.

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SCENARIO 3: The Nasogastric Tube Placement Checking

INVESTIGATION
The investigation team collected the key facts, including:

• The nutritional nurse specialist explained the hospital policy. This states
that only doctors who have been through eLearning and a
competency check in interpreting NG tube X-rays can confirm
placement. It takes a few weeks after junior doctors’ rotation to get
everyone through the training. The junior doctors’ induction includes the
very clear instruction that they must not check tube placement until
they have been trained. She explained that in some ways this training is
quite simple. It involves teaching doctors ‘four criteria’ for the specific
points to check along the track of the NG tube. This is in contrast to the
traditional but inaccurate methods of checking only the tube tip.
Almost everyone passes their assessment first time as long as they’ve
actually paid attention to the eLearning.

• The nutritional nurse specialist said she checked the records and
Dr Abdullah attended the induction session two weeks’ ago. He had
been sent the link to the eLearning to complete in advance of a
practical assessment scheduled for next Friday.

• The nutritional nurse specialist said nurses are expected to reinforce this
training. They only let doctors check tube placement if they are on the
intranet list of staff who have passed the assessment. The nurse specialist
said that in her view almost everything Nurse Jones did was in line with
policy and good practice. The exception to this was in asking
Dr Abdullah to check the tube without checking the list.

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SCENARIO 3: The Nasogastric Tube Placement Checking

INVESTIGATION

• Nurse Jones said he has worked on the acute stroke ward for four years
and knows how important it is to do these checks carefully. He said he
usually checks the list. However, both ward computers were being used
by colleagues at the time so he asked Dr Abdullah if he had been
through the trust’s training and had been ‘signed off’ to do these
checks. He said he assured him he had and he trusted him.

• Dr Abdullah said this is his first registrar post. He remembered being told
in his induction not to do these checks until he had been through the
trust’s training. He thought it was “bureaucracy gone mad” to expect
him to do more training and a test because he’d already learned this.
He said that in his foundation year at another trust a more experienced
junior doctor had shown him how to check if the tip of the tube was
below the diaphragm. He said that he had checked X-rays “hundreds
of times” since. He agreed with Nurse Jones’ general account of their
conversation when he asked him to check Mrs Tracey’s NG tube. He
said he had not been untruthful as he only told him he had been
through “the training” and that he “could check NG tubes” rather than
specifically stating that he had done this trust’s training and passed the
assessment.

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JUST CULTURE
The Science of Safety & The Principles of Error Management

Scenario No. 4
A Tragedy in Tennessee

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Scenario No. 4: A TRAGEDY IN TENNESSEE

Two days after Christmas in 2017, Charlene Murphey, a patient at
Vanderbilt University Medical Center, died after receiving an Intravenous
medication in error.

The medication was administered by RaDonda Vaught, an experienced

registered nurse who had retrieved the wrong drug and subsequently
failed to detect and correct her mistake.

Standard safety norms and technologies used to prevent and detect the
original error before it could reach the patient were absent or
incompletely deployed. The nurse, attempting to accomplish multiple tasks
simultaneously, did not perform standard visual checks that could have
surfaced the error.

In this tragic constellation of individual and system failures, patient

Charlene Murphey lost her life. Her family lost a beloved mother and
grandmother, and Ms. Murphey's community lost a treasured friend and
engaged citizen.

Eight days later, Vanderbilt University Medical Center fired RaDonda

Vaught, citing her failure to adhere to the Five Rights of Medication
Administration.

In July 2021, the Tennessee State Board of Nursing revoked RaDonda

Vaught’s nursing license and on March 25, 2022, she was convicted on
two criminal counts: criminally negligent homicide and gross neglect of an
impaired adult. She will be sentenced on May 13th in Davidson County, TN
and could serve up to 12 years in prison.

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SCENARIO 4: A Tragedy in Tennessee

INVESTIGATION
Roles & Responsibilities of the Help-All Nurse
• The Neuro-ICU designates a nurse (Help-All Nurse) to assist other nurses in
moving planned care forward for patients within the unit
• RaDonda Vaught is the designated Help-All Nurse on 26 December 2017
• She is the preceptor of a new-graduate RN, orienting to the Neuro-ICU
• The preceptor-preceptee dyad were preparing to go to the ED to perform
a swallowing study immediately before RaDonda is tapped to provide care
to Ms. Murphey

Prescribing the Medication

• The need for Ms. Murphey to have an anxiolytic was not anticipated,
creating an urgency when discovered after her arrival in Radiology
• A radiology team member alerted the primary nurse in the Neuro-ICU of
Ms. Murphey’s need for anxiolysis
• A provider’s order for an IV anxiolytic, midazolam, was secured
• The order was entered electronically (accurately)

Adaptive Care Planning

• The schedule was too busy for one of the Radiology RNs to administer the
ordered anxiolytic
• Ms. Murphey’s primary nurse could not go & sought task-assistance from
the Help-All nurse to prevent the case from being cancelled
• The name of the ordered anxiolytic was communicated verbally between
the primary nurse & RaDonda as Versed
• Neither the primary nurse nor RaDonda routinely administer Versed
• Patient monitoring was discussed by the primary nurse and the Radiology
Tech with the primary nurse concluding monitoring was not indicated
• Patient monitoring was discussed by the primary nurse and RaDonda, with
the same conclusion. RaDonda did not plan to provide monitoring to
Ms. Murphey

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SCENARIO 4: A Tragedy in Tennessee

INVESTIGATION

Pharmacy Review
• The timeliness of pharmacy review of provider orders was variable
• EHR – ADC interface change in November 2017
• RaDonda recalls emails supporting use of OVERRIDE to assure timely care
• Ms. Murphey received ~ 20 drugs via OVERRIDE
• RaDonda concludes pharmacy review of Ms. Murphey’s anxiolytic will not
occur timely
• The ordered medication has been reviewed and is listed on the pt.’s ADC
profile as midazolam
• RaDonda does not know midazolam is the generic name of Versed
• She elects to use the ADC’s override function

ADC Drug Procurement

• RaDonda’s preceptee is present at the time of drug selection. She is
multi- tasking & recalls focus of conversation as the upcoming procedure in
the ED
• Types in V-E
• Vecuronium appears at the top of the list
• Selects it
• Interacts with standard warnings that were present for all drugs removed on
OVERIDE
• Vecuronium, a paralytic, was not constrained nor differentiated from other
vials in the ADC nor through programmed screen warnings
• RaDonda removes the <wrong> drug from the ADC bin
• Upon retrieval, she notes powdered formulation; flips the vial and begins to
read reconstitution directions on the back of the label
• She does not read the label on front of vial

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SCENARIO 4: A Tragedy in Tennessee

INVESTIGATION

Drug Administration
• RaDonda locates and identifies Ms. Murphey in the Radiology corridor
• She attempts to locate an EHR terminal and barcode scanning
equipment
• Barcode scanning is not in place in the Radiology area
• EHR access for documentation is not available
• RaDonda does not read the drug name or appreciate the warnings on
the vial label
• She reconstitutes the medication & administers it IV via central venous
catheter
• The Radiology Tech is present while the medication is administered

Drug Monitoring
• RaDonda is not familiar with Radiology norms, flow or competing
priorities within the Radiology Suite
• Ms. Murphey is taken to a Holding Area by the Radiology Tech
• Nurse Vaught and the preceptee proceed to the ED as planned
• The Holding Area where the patient awaits PET scanning is equipped
with a surveillance camera
• Post-administration drug monitoring does not occur
• Ms. Murphey is discovered unresponsive ~25 minutes later.
• She undergoes resuscitation but experiences brain damage such that
supportive care is withdrawn the next day

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The Science of Safety & The Principles of Error Management

Scenario No. 5
Pulmonary Embolism

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Scenario No. 5: Pulmonary Embolism

Nurse was busy in PACU handling multiple admissions late Wednesday
afternoon. She was getting Patient settled in as he listened to Surgeon, and
Cardiologist, discuss patient’s case.

SURGEON:
“Patient’s Total Hip Replacement was a success, but she’ll probably need a bit
longer to than usual to recover. She lost a lot of blood & received a lot of fluid in
the OR. It’s too soon after her surgery to start anticoagulation. I’m also
concerned about her getting out of bed too soon. She needs rest.”

CARDIOLOGIST:
“She should be started on her home medications immediately. Especially her
anti-coagulation & anti-hypertensive medications. She’s 85. We can’t afford her
throwing a clot & having a stroke. Also, we need to her out of bed as soon as
possible. Early mobility will be key. Let’s hold off on her anti-coagulation
medication for a little while, but make sure she wears her TEDS & SCDs and gets
out of bed tomorrow to walk a bit.”

SURGEON:
“Alright, and we’ll order an echocardiogram in the morning. Nurse Sarah, did
you get that?”

NURSE SARAH:
“I don’t have any questions right now. I can check your notes when I have time if
I need to clarify anything.”

SURGEON:
“Ok, I need to get back to the OR though. I ’ll get the notes in when I can.”

The PACU gets even busier, Nurse Sarah gets ready to transfer patient to
the floor. She calls Nurse Dana, the ward nurse, that evening, relying on
memory for the report.

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SCENARIO 5: Pulmonary Embolism

NURSE SARAH:
“The surgical team wants patient’s home medications held. And they want echo
first thing in the morning because she received a lot of fluid in the OR. I would just
keep her in bed until that’s taken care of, also when physically assessing her I
noticed her skin was very fragile, so I didn't put on her SCDs. I figured those could
wait. You might want to check her again.”

Nurse Dana held patient’s medication & decided to use SCDs after feeling
the older woman’s skin the next morning. However, there was none in
stock and Nurse Dana was interrupted when a code was called in another
room so she couldn't go look for more.

When she next checked on the patient, Nurse Dana didn't see any notes
from the surgeon about the case. She continued to hold the patient’s
medications and decoded ultimately not to go look for SCDs because she
was afraid that older woman might fall if she tried to ambulate with it.

The physiology unit was backed up and the transport team didn't arrive to
take patient for Echo until late in the evening. Patient remained in bed all
day and became hypertensive. Her right leg began to swell. Nurse Dana
caught it in time, but she’s devastated by the thought that patient might
have suffered from a pulmonary embolism.

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The Science of Safety & The Principles of Error Management

Scenario No. 6
Medication Error — Omission of Dose

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Scenario No. 6: Medication Error — Omission of Dose

Kelly is a new ICU nurse, just a few weeks from the end of her six-month
orientation in a busy ICU. She had a heavy patient load on a day that
included care of chronic patient.

A tech was assigned to work with Nurse Kelly on this day, but the tech was not
feeling well and went home before Nurse Kelly stepped foot in eithers
patient’s room.

Patient No. 1
Mr. Adam is recovering from a ventral hernia repair, lysis of a adhesion and small
bowel resection. He had been in the OR for 9hrs. And had a estimated blood loss of 1
liter due to a nick in his mesenteric artery. Due to past medical history of
chemotherapy and radiation of colon, small bowel resections and recurrent ventral
hernias with multiple repairs. The anesthesiologist had a difficult access in his feet to
insert lines. After multiple try doctor was finally able to place. A left upper extremity a
peripheral IV and a left foot peripheral IV. Because of the lines no SCDs or TEDs were
applied.

Patient No. 2
Mrs. Jones is a 72 years old chronic patient who had been in the ICU for about a
month. She was coping with end-stage renal disease and heart failure. She had no
family members supporting her and felt alone and afraid. She used call button both
for her medical needs and to get a chance to talk to the nurses.

When Nurse Kelly was finally able to check on Mr. Adam, she saw that he was
comfortable and seemed stable. She was behind on orders and taking a
second look at the medications she needed, she noticed an order for
subcutaneous (subcutaneous) Heparin. It was 1600, and the order was placed
for noon. There was no heparin in the patient’s medication drawer.

NURSE KELLY:
“I am so behind and the pharmacy messed up. I know heparin was timed for every 8
hours. I will sign off the noon order so the next shift can administer it at 2000H.”

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SCENARIO 6: Medication Error — Omission of Dose

Nurse Kelly administered the other medications due at noon but did not
administer heparin. She rushed off to answer the call bell of Mrs. Jones, her
chronic patient.

Nurse Kelly didn’t want to admit she had difficulties handling her
assignment, so she failed to tell her senior nurse that Mr. Adams didn’t
receive the noon dose of heparin.

At the shift change, the oncoming nurse didn’t administer heparin

because Mr. Adams was off the unit receiving a CT scan. Seeing that the
noon dose had been signed off on, he noted the 2000H dose as not done
because Mr. Adam was off the unit.

At 0400 that day, Mr. Adams experience a pulmonary embolism.

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The Science of Safety & The Principles of Error Management

Scenario No. 7
Near Fall

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Scenario No. 7: Near Fall

A junior occupational therapist was about to end her session with a 62 years
old lady with spinal cord injury (complete T4 level). This is the patient’s 3rd
week of rehabilitation as in-patient. The therapist put the wheelchair at the
side of the hi-lo mat bed to begin the transfer of the patient by side way
scooting using the sliding board.

While preparing the patient, the junior occupational therapist thought…

“I will no longer use the gait belt as I have been transferring this patient successfully
without using that. I have been doing this. I am sure I can do this again like I have
always been.”

However, before starting the transfer, the patient leaned forward and she was
not able to control herself. The therapist tried to control the patient but she
could not manage to reposition her and just decided to assist her to fall safely
on the floor. The therapist with the assistance of the sitters transferred the
patient back to the wheelchair.

The sitter of the patient verbalized to the therapist that she saw the patient’s
leg not well positioned when she sat on the floor a while ago.

The sitter verbalized her concern to the therapist…

“My grandmother might have injury from how she sat on the floor after the near fall.
Her legs are not well positioned.”

JUNIOR OCCUPATIONAL THERAPIST:

“I believe she’s fine as she was only about to fall but she did not. I assisted her to sit
on the floor…”

The junior occupational therapist ignored the sitter’s concern…

And said to herself…
“I don't think that there is need to report this to my supervisor nor make an incident
report regarding this issue. As patient was not harmed anyways and I am not familiar
to report IR.”

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SCENARIO 7: Near Fall

On the next session, the patient together with her sitter went to the PT session.

The sitter informed the senior PT therapist (who happened to be the supervisor
of the Junior OT) about the incident that happened during the OT session…

SITTER:
“I have a concern that my grandmother might had sustained an injury during the OT
session. She had a near fall and she was assisted to sit on the floor. However, while on
the floor, her legs are not properly positioned.”

SENIOR PHYSICAL THERAPIST:

“Let’s proceed with the therapy session. Shall we?”

PT was in a rush… She did not value the concern of the patient’s sitter. She
also did not communicate this incident with the nurses & the treating
physician.

The next day, the sitter noted swelling on the patient’s thigh and she reported
this to the nurses.

Upon further interview by the nurses with the patient and the sitter, they
verbalized that the patient had fall incident one day before and she might be
fractured from that fall or during the PT session.

Physician was informed for further assessment and management and the x-ray
revealed a fracture on the femur which needs surgical intervention.

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Quality Management 2022

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