# Pneumothorax Case and Instructors Guide

**NOTE: This teaching case has elements from many real case studies, but
many details were manufactured to provide enough information to
accomplish the RCA Team exercise**

**Team Members** 1) Radiology resident (not involved in this case)

2\) Radiology physician (not involved in this case)

3\) Nurse from a similar unit

4\) Department manager (not radiology, but similar)

**Event has occurred before** \-- most recently on 2/2/99

*Corrective actions at that time* included: **awareness training** for
residents on service; **changed procedure** to have follow-up chest
X-rays done within 2 hrs, unless there was a change in status

### Summary of the Event

A.B. is a 55-year old male who was found to have a solitary pulmonary
nodule in the upper lobe of his right lung detected on a chest X-ray,
which was taken for possible pneumonia. He was subsequently seen by a
pulmonary medicine consultant who advised a CT scan guided fine needle
biopsy of the lung nodule. The clinic physician and nurse both informed
the patient there was likely to be minor discomfort after the procedure
and it would not be necessary to stay overnight.

A.B. was admitted to the short stay hospital unit (SSU) on the morning
of 11/1/99 to have a CT guided biopsy of the lung nodule by an
interventional radiologist. After he was mildly sedated, the patient was
transported to the radiology department. The patient also had an IV
catheter inserted and cardiac rhythm and blood pressure monitors
attached. The interventional radiologist was assisted by a radiology
resident. The role of the resident was to learn the technique by
assisting with the procedure and monitoring the patient. The CT scan
image was used to locate the lesion. The radiologist inserted a needle
through the chest wall into the nodule and aspirated tissue for the
specimen. After the needle was withdrawn both clinicians noticed a
**small (\~10%) pneumothorax** (air inside the chest cavity but outside
the Right lung), a common complication. The partially sedated patient
had no complaints and denied any shortness of breath or pleuritic chest
pain.

After a 15-minute delay in transport, the patient was taken back to SSU,
and monitors were re-attached. In the next 30 minutes, no staff had
directly checked on the patient. During that time, the pulse oximeter
alarmed "low oxygen" repeatedly, but the patient began to silence the
alarm as he previously had learned to do. The patient was surprised that
he had right-sided chest pain with inspiration but he did not inform his
nurse. He had rationalized this pain as a transient problem that would
soon disappear.

**Summary of the Event -- Pneumothorax (cont.)**

Fifteen minutes later, the nurse noticed A.B. silencing the alarm and
grimacing. After checking vital signs, viewing his pulse oximeter and
looking at the chart, she requested a follow-up chest X-ray to be done
ASAP. She also called the interventional radiologist. Blood pressure,
heart rate, and respiratory rate were all elevated. The radiology notes
in the chart were impossible to read, and she remembered that the
resident usually dictated procedure notes.

The chest X-ray now showed a **50% pneumothorax**. A thoracic surgery
resident was called, and he inserted a chest tube to re-expand the right
lung. The chest tube remained in place for three days due to a
persistent air leak. The patient was discharged home 4 days after the
biopsy procedure.

**Immediate Actions:**

1)  An X-Ray was taken.

2)  A chest tube was placed.

3)  Patient was cared for with IV fluids, pain medications, and watched
    closely with a cardiac monitor and pulse oximeter.

4)  The records kept in the radiology department were copied.

5)  The pulse oximeter was sent to clinical engineering for testing.

6)  The Facility Director was told about the case on 11/2/99 (24 hours
    after the event).

**Other Useful Data:**

1)  Patients are usually evaluated **every 5 minutes** after a procedure
    with continuous pulse oximetry.

2)  The pulse oximeter was found to have **no malfunctioning** parts.

3)  The SSU was a new concept for this VA facility (2 months old).

4)  The patient signed a consent form.

#### Instructors Guidebook- Pneumo Case

**Began each session by doing the following:**

> **1)** Identify that you will act as *RCA Advisor*
>
> **2)** Assign or confirm who is the *RCA Team Leader* and
> *Recorder/Secretary*
>
> **3)** Make sure each team member has a blank *RCA Form* and *Triage
> Questions* out in front of them

## Gradually let the Team Leader become the Leader...

**1)** [Expect that some RCA Team Leader with be reluctant,]{.underline}
you need to let them struggle a bit to show risk managers that they need
to pick, train, and be ready to support their team leaders

> **2)** Let the [RCA Team Leader draw the flow charts and lead the team
> through most items]{.underline}; you will probably need to prod and
> guide with triggering questions
>
> **3)** When creating Actions and Outcomes, you many need to take the
> RCA team back to root causes that were poorly worded
>
> **4)** DO NOT let the Team stray from the "key" points listed below --

\- They need to address the key points first (at least)

> \- You should help them write, or rewrite at [least one row in Table
> 19 that is "correct"]{.underline}

## Key Problems or Issues with Previous Training Teams

**1)** They might not want to draw an initial flow chart; jumping to
root causes or solutions

**2)** They might want to spend a lot of time drawing an overly detailed
flow chart

**3)** They might not understand why the triggering questions help

**4)** They might get distracted by minor or moderate details about the
"medical" parts of the case

(We are attempting to improve the medical details to avoid this)

**5)** They might focus on the shortcomings of people
(blaming-training), not systems redesign

## [Key Points to be Covered for this Case Study]{.underline}

## (Your Team Should Focus on These Items and Triggering Questions First)

## 

**I) ACTUAL SAC = 2,... But POTENTIAL SAC = 3**

\- Team could say delay caused increased length of stay  moderate

\- Team could say delay caused permanent lessening of function  major

**II) HUMAN FACTORS/COMMUNICATION**:

**HF/C 2-8** -- Was info from various assessments and diagnostic
work-ups shared, etc... (read all of the first eight questions -- all
apply to one degree or another)

> Key items for questions 2-8
>
>  Missing information on chart
>
>  No communication about small pneumothorax
>
>  Patient's reluctance to ask for help or be evaluated
>
>  New hand-offs and communication procedures for new SSU

**III) EQUIPMENT:** Pulse oximeter and its alarm

**E6** \-- Was the equipment designed to properly accomplish its
intended purpose?

> ***Yes,** but team could question the overall purpose of oximeter
> being a "primary" monitor*

*The team may ask about the sensitivity of settings on the oximeter.*

**E16** -- Was the design such that mistakes of use would be unlikely to
happen

***No,** the patient had seen others staff hit silencing the button all
the time.*

> **E21** -- Was the equipment designed so that corrective actions could
> be accomplished in a manner that minimized/eliminated any undesirable
> outcome?
>
> ***No,** easily accessible silencing switch location.*

**IV) Rule 4 -- Each procedural deviation must have a preceding cause**

**(From FIVE RULES OF CAUSATION)**

TEAM MIGHT SAY: *"nurse did not follow procedure"* (i.e., blaming
patient or nurse)

You want them to focus upon  NORMS FOR ALARMS AND CHECKING PATIENTS:

> Discuss what might be the **positive and negative incentives** that
> created [NORMS]{.underline} for:
>
> \- Not reacting to alarms
>
> \- Not following standard procedures for checking patients

**Issues and Answers (General)**

-   **Q:** Why hadn't the presence of a \~10% pneumothorax been
    communicated to the SSU nursing staff?

    -   **A:** The radiology resident was busy with another patient and
        forgot to call the SSU.

-   **Q:** Why was the patient not assessed immediately after returning
    to the SSU?

    -   **A:** The patient's nurse was busy preparing her other patient
        for the OR.

-   **Q:** Why wasn't the patient educated on the use of the pulse
    oximeter and told not to shut off the alarms?

    -   **A:** The nurse does not have enough time to educate her
        patients regarding pulse oximetry.

-   **Q:** Was there a standard procedure for the resident to order a
    repeat chest X-ray after an initial pneumothorax was discovered?

    -   **A:** No-but that is the general practice after such a
        procedure.

**Interview Questions/Answers (related to issues above):**

-   **Interventional Radiologist**

    -   **Q:** What is the usual procedure for communicating the details
        of a procedure's outcome and complications to the patient's
        nurse?

        -   **A:** I'm not sure there is a standard procedure but
            usually I write a quick note in the chart but the resident
            generally writes or dictates a more extensive procedure note
            and usually speaks to the nurse if a complication occurs
            that the nurse needs to be aware of.

    -   **Q:** In this case why wasn't the pneumothorax reported to the
        nurse so the patient could be closely monitored?

        -   **A:** The resident usually does follow up with nurse on the
            floor after a procedure where a complication occurs.

    -   **Q:** Do you usually order a follow-up chest x-ray on these
        types of cases?

        -   **A:** Yeah-the residents know they need to do that.

-   **Radiology Resident**

    -   **Q:** What is the usual procedure for communicating the details
        of a procedure's outcome and complications to the patient's
        nurse?

        -   **A:** I usually dictate a procedure note and write a note
            in the chart. If there is something the nurse needs to know
            more urgently I give her a call.

    -   **Q:** In this case why wasn't the pneumothorax reported to the
        nurse so the patient could be closely monitored?

        -   **A:** I called up to SSU but the patient's nurse was busy
            so I planned to try again later-I dislike leaving messages
            with the covering nurse. We had a really busy schedule that
            day and before I could call her back I had heard about what
            had happened from my attending.

    -   **Q:** Do you usually order a follow-up chest x-ray on these
        types of cases?

        -   **A:** Yeah, I always do but that day was crazy and I just
            didn't get to it in time. The team taking care of the
            patient upstairs usually catches that kind of thing and
            places the order. We really weren't worried about this
            patient. His pneumothorax was small and didn't seem to be a
            problem.

-   **SSU Nurse**

    -   **Q:** What is the usual procedure for communicating the details
        of a procedure's outcome and complications to you?

        -   **A:** I usually just read the notes in the chart and wait
            for the dictation from the resident because it is much
            easier to read. If there was a problem with the procedure
            they are supposed to let me know.

    -   **Q:** Why did it take so long for the patient to get assessed
        once he got back to the SSU?

        -   **A:** I'm really pretty good about checking in with them as
            soon as they get back from a procedure. That day I was busy
            preparing another patient for the OR when the patient got
            back. The nurse that was covering was one of those agency
            nurses and really doesn't know her way around yet. She just
            didn't get to check on him after the procedure because she
            was busy with another patient.