Case 27 A major mix-up

Mr Johnson is a 68-year-old man who has type 2 diabetes and mild COPD. He becomes unwell at home with a fever and pleuritic chest pain but delays seeking medical help. By the time his GP is asked to see him, Mr Johnson is hypotensive with septic shock and an emergency admission to hospital is arranged.

What treatments should be instituted upon Mr Johnson’s arrival at hospital?

The core medical trainee who first sees Mr Johnson, Dr Hewitt, appreciates the gravity of the situation and immediately gives intravenous ceftriaxone, oxygen and intravenous saline and commences an insulin sliding scale. He also prescribes subcutaneous low molecular weight heparin for venous thromboprophylaxis. A chest X-ray shows widespread consolidation in the left lung field. Mr Johnson is significantly hypoxic with oxygen saturations of 82% despite 28% oxygen. Blood gases show he is acidotic with a pH of 6.99 and a lactate of 7 mmol/L. With aggressive fluid resuscitation, Mr Johnson’s blood pressure increases and over the next hour or so he begins to improve.

On the post take ward round, the Consultant decides to administer intravenous sodium bicarbonate because Mr Johnson still has ‘acidotic breathing’ although his condition is now more stable and he is producing a good urine output and appears to be less confused.

Do you agree with this decision?

Two hours later Mr Johnson suddenly becomes more unwell and rapidly loses consciousness. A cardiac arrest call is put out and on arrival the team find Mr Johnson to be asystolic. Despite a prolonged attempt to resuscitate him, Mr Johnson dies. As the arrest team are writing up the details of their treatment, the anaesthetic registrar asks ‘Why he was he receiving iv lidocaine?’ The nurse who had been looking after Mr Johnson denied he was, but on inspection it is clear that the pre-prepared and packaged giving set does indeed contain lidocaine and not bicarbonate as intended and prescribed clearly on the drug chart.

Who should be informed of this death?

The case is reported to the coroner who refers it to the police. The police interview the nurse and ask him if he checked the infusion before connecting it up. The nurse says ‘I couldn’t have done’ and at this stage he is cautioned by the police and informed he may be charged with manslaughter (although after a year, a decision is made not to pursue charges).

It later transpires that the nurse was working single handed in a very busy bay with three particularly sick patients. He did not feel he could ask for help to check the infusion when he set it up because his colleagues were similarly busy. He remembered seeing a box containing pre-packaged bicarbonate on the ward and went and picked one out to give to Mr Johnson. In fact the box did contain pre-packaged infusion bags of bicarbonate but somehow a single bag of lidocaine had been mixed in with the bicarbonate bags during a recent ward stock-taking exercise. Superficially the pre-packaged bags all look the same and the most prominent label is not the drug contained within them but rather the company trade name (in this case, Polyfusor®). The confusion was understandable but the checking had been too cursory to detect the similarity and avoid the problem.

Following on from this incident, the Health and Safety Executive undertook an investigation of the working environment. A number of factors were identified including the adequacy of lighting in the cupboard, the organization of supplies and the hours worked by the staff nurse concerned.

Expert opinion

The initial management of Mr Johnson by the core medical trainee was appropriate and timely. The decision taken on the post-take ward round to prescribe bicarbonate was subsequently questioned as no further blood gas analysis had been undertaken and Mr Johnson was clearly improving. Bicarbonate is not without risk and may not have been required if the acidosis had significantly improved. The prescription for bicarbonate was clearly and correctly written and the nurse was asked in person to commence the infusion.

The use of pre-packaged infusions is an important way of avoiding errors that might otherwise occur in calculating and preparing or diluting an infusion. However the first error in this case was that a lidocaine bag had become mixed in with the bags of bicarbonate during a ward stock take. In fact some years earlier a similar episode had occurred and as a result of that all pre-packaged infusions of lidocaine had been removed from general wards and non-resuscitation areas. Unfortunately Mr Johnson was on the medical assessment unit where lidocaine was held as stock and there was a lack of awareness of the potential for confusion. It is a recurring theme that all too often products which superficially look alike are stored together.

This fatal drug administration error occurred because of a combination of system errors, a catalyst event and then simple human error. The system errors included inadequate staffing, leading to a stressful environment. The nurse was inexperienced and being asked to cover too many sick patients at once. The drug packaging was confusing and storage facilities were poor. The catalyst event was that unusually a stock take had occurred on the ward that day and all of the Polyfusor® bags placed in a single box. The human error was the failure to check adequately even though he did recall looking at the bag – in haste and presumably he saw what he wanted to see. Once the infusion bag had been set up and connected it is highly unlikely that the error was going to be picked up and the catastrophic outcome had been set in motion.

Legal comment

This adverse incident illustrates how one set of events can result in a number of appropriate investigations by different agencies. The unexpected death of the patient was reported to the coroner. Since one of the root causes of the patient’s death was the action of the individual nurse in selecting the incorrect drug, the coroner appropriately informed the police. It is rare for healthcare professionals to be investigated for a criminal offence arising from patient deaths associated with clinical practice. As we have seen in other case studies, the more usual route for legal investigation and remedy of patient harm is through the civil system. Conviction for a criminal offence requires proof beyond reasonable doubt that the person charged has carried out an unlawful act (actus reus) and had the state of mind (or intention) to carry out the act (mens rea). Both elements must be present for a successful criminal prosecution.

The police and Crown Prosecution Service (CPS) considered a charge of manslaughter by gross negligence against the nurse. The charges of murder and manslaughter are distinguished by the state of mind of the defendant. In this case study, the actions of the nurse were part of the cause of the patient’s death; but the nurse did not have any intention to kill or cause serious injury to the patient. The definition of manslaughter by gross negligence requires the existence of a duty of care; breach of that duty; death occurring as a consequence of the breach of duty and a reckless disregard for the safety of others justifying a criminal conviction. In the context of this case study, the CPS needed to assess if a jury would consider the nurse had appreciated the risk and intended to avoid it, but displayed such a high degree of negligence in the attempted avoidance as to justify conviction for inattention/failure to advert a serious risk in respect of an obvious matter.

It is important to remember to retain the evidence (for example, the Polyfusor® bag) in any adverse incident in case items are required as evidence by the coroner or the police.

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