Learning from adverse events

​Earlier this year I was involved in the resuscitation of a child who suffered a cardiac arrest in our department. She had inadvertently received an overdose of phenytoin after being intubated for status epilepticus.

A whole team of dedicated professional staff were looking after her, and every member of that team was working hard to give her the best possible care. Despite this, she still received the incorrect dose of phenytoin. This post is intended to share learning and encourage staff to reflect on the human factors which contributed to this serious incident. Please read it carefully and consider how, despite best intentions, errors can easily occur, particularly during stressful and rare clinical scenarios.

Case

​An alert call was received from the ambulance service regarding a child who had been seizing for 30 minutes. On arrival the patient was unconscious, with a partially obstructed airway, vomiting, with ongoing abnormal posturing and in respiratory acidosis. Lorazepam was administered with no clinical change.  A rapid sequence induction was undertaken and the patient was intubated successfully. Treatment with ceftriaxone, morphine, midazolam and phenytoin was commenced. 10 minutes later the patient went into an asystolic cardiac arrest. CPR was commenced immediately, and consideration of reversible causes undertaken, including possibility of reaction to phenytoin. Intralipid was given after advice sought from NPIS regarding potential treatment for phenytoin toxicity, as no specific information available on the website. Resuscitative efforts continued for 60 minutes. The patient had a ROSC and underwent stabilisation, CT head and transfer to PICU later that night.
There were 4mls left in the phenytoin syringe and it was sent to pharmacy for analysis. One week later pharmacy confirmed the syringe contained neat phenytoin. The patient had therefore received a significant overdose. As soon as the error was identified, a DATIX was completed and a serious incident review commenced. Duty of candour was applied and the patient’s mother was informed.

Serious Incident review

​One of the first steps in this process is to contact the staff involved and ask for their recollection of events. As a staff member this can be very difficult. The vast majority of health professionals work hard with the intention of giving good care. The staff involved in this incident were contacted by the lead reviewer and their local line managers, and asked to provide a verbal or written report.
These reports were then collated, and a root cause analysis meeting held to discuss the incident, inviting all involved staff to attend. A root cause analysis report was then produced; sharing lessons learned and recommendations. The following pages contain excerpts from that report, please consider the human factors elements that contributed to the error and the impact these can have on our daily practice.

Areas of good practice

• Excellent communication demonstrated between the teams even though a number of different specialities involved in the care.
• Immediate recognition of the change in patient’s condition with prompt commencement of CPR and a thorough and rapid assessment of the potential causes for this. 
• Team utilised the available resources of a paediatric drug calculator and infusion policy.
• Prompt summoning of paediatric anaesthetic help.

Care & Service delivery problems

• The care of a critically ill child is emotive
• Busy, distracting environment with staff at the end of a long shift without sufficient rest periods.
• Single paediatric trained nurse utilised with heavy reliance on her understanding of paediatric medicines by other staff present.
• Multiple medications requested simultaneously. No signature on phenytoin prescription – written up as stat dose not on infusion chart although does state give over 20 minutes.
• Phenytoin monograph describes two ways to administer phenytoin, one neat and one dilute, these are next to each other
• Senior paediatric medical and nursing staff support requested late into the resuscitation.
• Drug drawing up area is cluttered and in the centre of the resus room with multiple distractions

RCEM Safety Alert phenytoin_toxicity_-_nov_2016.pdf
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