Root Cause Analysis: Prevent Patients from Missing Critical Cardiac Medications

Bon Secours Memorial College of Nursing

NUR 3241: Quality Safety and Nursing Practice

Jamie Driggs, RN

June 12, 2021

“I pledge…”
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Introduction

I work in the stress lab at St. Francis Medical Center (SFMC) and I perform several types

of stress tests for patients with a wide range of cardiac histories, symptoms, and reasons for

needing stress testing. Stress testing can be done in a variety of ways, based on the physical

capabilities of the patient, their specific current conditions or diagnoses, the reason for

performing the test, and insurance authorization.

For example, if a patient went to their physician with a complaint of palpitations

whenever they are physically active, a basic electrocardiogram treadmill stress test would be

appropriate to evaluate for activity induced arrhythmias. Or let us assume there is a patient

presenting with shortness of breath and the cardiologist wants to evaluate for the potential of

blockages in the coronary arteries, but the patient is unable to walk on a treadmill long enough to

raise their heart rate to the necessary range; a stress echocardiogram can be performed with

intravenous dobutamine as the stressing agent, or a nuclear stress test can be performed with

Lexiscan (an intravenous vasodilator medication) as the stressing agent. Apart from patients who

weigh more than 450 pounds, there is a stress test available that any patient could be eligible for.

I have encountered multiple patients reporting that they stopped taking medications in

preparation for their stress test, especially cardiac-related medications, that did not need to be

held. It can be extremely dangerous for a patient to abruptly stop taking certain medications.

Some examples of these medications include benzodiazepines, benzodiazepine receptor agonists,

opioids, proton pump inhibitors, antidepressants, anticoagulants, antiseizure, anticholinergic, and

antihypertensives. (Spindler & Tarsy, 2021; Steinman & Reeve, 2021)

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For this root cause analysis, I will be emphasizing the importance of cardiac related

medications. Throughout this essay I will examine potential causes, review contributing factors,

share my recommendations, and discuss the nurses’ role in the recovery/improvement process.

Problem Statement

In preparation for stress testing, patients are not taking their prescribed medications,

which could result in significant harm to the patient.

Causes of the Problem

Each type of stress test has its own individual requirements. For a dobutamine stress

echocardiogram to be performed effectively, patients should hold beta blocker medications for

24 hours prior to testing (Askew et al., 2019). Alternatively, for a Lexiscan nuclear stress test to

be performed, the patient must abstain from caffeine for a minimum of 12 hours (ideally 24

hours) prior to the test (Tejani et al., 2014; Askew et al., 2019). This includes coffee (even

decaffeinated), tea, soda, chocolate, and any medications that contain caffeine such as Fioricet.

According to Askew et al. (2019), the patient’s current medications need to be reviewed

and the decision to hold certain medications prior to testing should be determined on a case-by-

case basis. Especially when considering antihypertensive medications such as beta blockers and

clonidine, an abrupt discontinuation holds the potential to cause a severe rebound effect (Elliott,

2019).

However, stress testing can be ordered by primary care providers, family medicine

providers, cardiologists, surgeons (for pre-operative clearance), pulmonologists, and essentially

any physician who deems the testing as appropriate for their patient. Yet, based on the specialty

of the ordering physician, they may not know specific contraindications and pre-procedure

instructions to teach their patients. Imagine a physician ordering an exercise stress

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echocardiogram for a patient that is wheelchair bound. I am aware of how extreme it may sound,

but I have personally seen it happen.

Contributing Factors

By utilizing the cause and effect (fishbone) diagram, I have been able to determine

multiple contributing factors. Simple factors include the patient did not take their medications

because they were required to not eat or drink after midnight, because the medications are to be

taken with food, or that the patient takes certain medications at specific times throughout the day.

Patients also reported that they had received multiple phone calls with automated

appointment reminders that reviewed their pre-procedure instructions, which often differed from

the initial pre-procedure instructions that they were given upon scheduling their appointment.

When investigating this further, I realized that patient could be receiving pre-procedure

instructions from multiple sources, such as their primary care physician, the schedulers making

the appointment, a specialist physician that the patient reached out to, and the hospital stress lab

staff.

Depending on the pre-procedure instructions given to the patient, the instructions may

have been too vague by stating “hold cardiac medications the day before the procedure.” Some

patients may consider a medication to be cardiac related because it is taken for a cardiac

diagnosis, such as taking the blood thinner warfarin for a diagnosis of atrial fibrillation.

However, other patients may consider warfarin to not be cardiac related because they are taking

it for a blood clot in their leg (deep vein thrombosis). This type of instruction leaves too much

room for misinterpretation by the patient.

Recommendations
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Based on my analysis of this problem, I have developed two recommendations for

review.

Firstly, we need to streamline the process of how many phone calls, messages, and emails

that the patient receives for a single appointment. We could facilitate a meeting between the

stress lab and the scheduling department to review the ‘scripts’ that they use for providing pre-

procedure instructions for accuracy and make adjustments as necessary to reflect the current

practices and guidelines. Minimizing repetitive automated calls would reduce confusion as well.

Perhaps eliminating automated calls and allowing the stress lab nurses to call patients the day

before their scheduled procedure would be most beneficial to the patient.

Secondly, we need to educate ordering physicians of the types of testing we offer, and

what is appropriate for each patient's specific needs. I propose allowing the stress lab nurses to

create an informational handout, with approval from the cardiologists, that includes the following

information: the name of the test, the goal of testing, special considerations, and pre-procedure

requirements. This page could be something that physicians less familiar with the specifics of

stress testing could refer to when ordering and discussing with their patients.

Nurses’ Role in Recovery Process

The nurses’ role in this process improvement predominately falls onto the nurses working

in the stress lab and conducting the stress tests. Based on my recommendations, the stress lab

nurses would need to incorporate the practice of calling patients the day before their appointment

to discuss instructions and answer any questions. The stress lab nurses would also need to

collaborate with the cardiologists and establish appropriate guidelines to present to other medical

professionals and practices.

Conclusion
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Patients can inadvertently put themselves at significant risk by abruptly stopping their

prescribed medications in preparation for a stress test. Current practices for providing patients

with pre-procedure instructions are confusing and leave too much room for misinterpretation by

the patient. To reduce the risk of harm to our patients we need to educate providers who order

stress testing on the importance of individualized medication instructions for testing. We need to

collaborate with the scheduling department to clarify appropriate pre-procedure instructions

regarding medications and reduce automated calling in reference to scheduled appointments that

contains any pre-procedure instructions. The stress lab nurses should be empowered to assume

the role of reaching out to patients prior to their scheduled procedure to ensure the patient’s safe

understanding of the instructions they have received.

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References

Askew, J. W., Chareonthaitawee, P., & Arruda-Olson, A. M. (2019). Selecting the optimal

cardiac stress test (W. J. Manning & T. F. Dardas, Eds.). UpToDate. Retrieved June 9,

2021, from https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stress-test

Elliott, W. J. (2019). Withdrawal syndromes with antihypertensive drug therapy (G. L. Bakris &

J. P. Forman, Eds.). UpToDate. Retrieved June 10, 2021, from

https://www.uptodate.com/contents/withdrawal-syndromes-with-antihypertensive-

drugtherapy

Spindler, M. A., & Tarsy, D. (2021). Initial pharmacologic treatment of parkinson disease (H. I.

Hurtig & A. F. Eichler, Eds.). UpToDate. Retrieved June 8, 2021, from

https://www.uptodate.com/contents/initial-pharmacologic-treatment-of-parkinson-

disease

Steinman, M., & Reeve, E. (2021). Deprescribing (K. E. Schmader & J. Givens, Eds.).

UpToDate. Retrieved June 8, 2021, from https://www.uptodate.com/contents/depre

scribing

Tejani, F. H., Thompson, R. C., Kristy, R., & Bukofzer, S. (2014). Effect of caffeine on spect

myocardial perfusion imaging during regadenoson pharmacologic stress: A prospective,

randomized, multicenter study. The International Journal of Cardiovascular Imaging,

30(5), 979–989. https://doi.org/10.1007/s10554-014-0419-7

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Appendix