The Victorian Institute of Forensic Medicine has recently published a poignant article including coroner findings which are enclosed and highlights the tragic implications of a child’s death associated with  Nursing Staff fixation Error. Fixation error is  the phenomenon whereby a person or group falls into a pattern of thinking that there is only one possible explanation. This can take on several forms, including task fixation on a procedure, or diagnostic fixation to the exclusion of other possibilities.

CASE #1 WITHOUT A TRACE

Précis Author: Libby Newman, Clinical Nurse Specialist, Forensic Pathology, Tasmania

CLINICAL SUMMARY

AM was a 3 year old boy who was fully immunised and healthy. His family travelled overseas for a holiday during winter, where he developed bronchitis that appeared to resolve by the time they returned home. A week later, he developed a cough that gradually worsened. Over eleven days, AM’s parents took him to three different medical centres where various clinicians reviewed him. It was initially believed AM had a chest infection and he was commenced on antibiotics.

On his second review, he was diagnosed with a viral upper respiratory tract infection and his parents were advised to give him paracetamol and ibuprofen. When he presented to the third centre with symptoms of fever and nausea, the clinician diagnosed him with otitis media and prescribed a further course of antibiotics.

AM’s case highlights a reliance often placed by clinicians on monitoring equipment where a ‘hands on’ assessment is required.

AM’s condition continued to deteriorate over the next three days so his parents took him to a private hospital emergency department. There, they were told by a doctor to present urgently to the emergency department of a nearby local public hospital. At the public hospital, AM was triaged as a category one and diagnosed with sepsis secondary to left lower lobe pneumonia.

His respiratory rate was 28 breaths per minute and he required a non-rebreather mask at 8-10L flow to maintain oxygen saturations of 97%. He was commenced on oxygen, antibiotics and intravenous fluids, and a urinary catheter was inserted to monitor his fluid balance. Over the next two days, AM’s condition failed to improve. Although he appeared more alert and was able to eat and drink in small amounts, he had increasing puffiness around his eyes and seemed to tire very easily. His respiratory rate was 30 breaths per minute and his oxygen saturations were 97% on 2L via nasal prongs. His pathology results showed hypoalbuminaemia and hyponatraemia.

Consultation about his condition with another senior paediatrician as well as a nephrologist from a children’s hospital ensued, and his biochemical abnormalities were thought to be more consistent with intravascular depletion than SIADH (Syndrome of Inappropriate Antidiuretic Hormone).

On day three of his admission, the treating team discussed the possibility of using intravenous albumin and oral salts as well as continuing AM’s crystalloid fluid maintenance. On the same day, AM’s catheter was removed as staff were concerned that it was blocked. During its removal, AM passed a large amount of urine and a loose bowel motion, soaking himself which distressed him. Nursing staff decided to shower him, removing his supplemental oxygen in the process.

AM’s father showered him whilst he sat in a chair. AM stood briefly at the end of the shower but then collapsed and his father carried him back to his bed. Two nursing staff re-applied the supplemental oxygen and a saturation monitor. The monitor did not show a trace and the nurses thought the monitor was faulty, so a second monitor was sought which did not show a trace either. A faint heart rate was eventually detected by the second monitor and an oxygen saturation reading of 95% was shown. AM’s father left the ward for approximately 10-15 minutes around this time.

On his return to the ward, the nurses were still checking the equipment. Another family member then noticed that AM’s chest was not moving. AM’s father went to the bedside and asked the nursing staff to examine him. AM was non-responsive and in cardiac arrest.

The nurses activated the emergency button but despite resuscitation AM was unable to be revived.

PATHOLOGY

AM’s cause of death was attributed to Influenza A (Type H3N2) with the manner stated as, “Cardiovascular collapse as a result of a combination of hypovolaemia, hypotension and hypoxaemia in the setting of a warm shower (with possible vasodilation) and period without supplemental oxygen.”

INVESTIGATION

AM’s death was investigated by an inquest held four years after his death with a focus on the fixation errors made by the nursing staff. Two expert witnesses, a senior staff specialist in paediatric intensive care and a consultant paediatrician, provided opinions at inquest that focused on the care AM received during his hospital admission. The coroner heard that the nurses had incorrectly focused on the monitoring equipment to the exclusion of recognising any other cues. Abnormal findings were then attributed to faulty equipment rather than the clinical condition. Both witnesses agreed that the management of AM’s dehydration and biochemical abnormalities could have been more proactive and instituted earlier, but they were nevertheless not overly critical of the treating team. This reliance can lead to a fixation error – which occurs when a clinician’s focus is centred on one facet of a case causing them to lose sight of other relevant information about the case. The Director of Clinical Services of the hospital where AM had been admitted provided evidence in regard to system improvements in the area health service since AM’s death.

These included: oxygen and/or monitoring not to be discontinued by nursing staff without prior discussion with the medical team, and an early tertiary opinion is to be sought for complex cases. In addition, a number of measures had been introduced to improve multidisciplinary team work, including: multidisciplinary training sessions, daily Patient Safety Huddles on the ward; and Paediatric Clinical Issues meetings, Patient Safety Meetings and Morbidity and Mortality meetings.

CORONER’S FINDINGS

The coroner stated, “the nurses fell into error in focusing too long on the monitoring equipment, without checking the physical signs of whether [AM] was breathing… the time between [AM] collapsing and the time of calling for medical review was unacceptably long, as a result of the fixation on the monitoring equipment”.

Staff across the health district address ‘fixation errors’, with particular reference to assessment of monitoring equipment results.

AUTHOR’S COMMENTS

AM’s case highlights a reliance often placed by clinicians on monitoring equipment where a ‘hands on’ assessment is required. This reliance can lead to a fixation error – which occurs when a clinician’s focus is centred on one facet of a case causing them to lose sight of other relevant information about the case. This phenomenon has been documented in various professions including healthcare, aviation and other fields where reliability of practice is essential. Enhancing a clinician’s awareness of their surroundings – or their ‘situational awareness’ – is an important strategy to countering fixation error. Incorporating situational awareness into training of all healthcare providers would foster a mindset of vigilance and an openness to assessing other possible causes of an issue.

The healthcare setting is dynamic, and technology can assist in monitoring and diagnostic processes, however, this case compellingly highlights the importance of a basic physical assessment every time.

RESOURCES

  •  Rodriguez A, Lee D, Makic MBF. Situational Awareness in Critical Care: An Aviation Approach to Reduce Error. J Perianesth Nurs 2017; 32(6): 650- 652.
  •  Sitterding M, Broome M, Everett L, Ebright P. Understanding Situation Awareness in Nursing Work: A Hybrid Concept Analysis. ANS Adv Nurs Sci 2012; 35(1): 77-92.

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