Saturday, February 29, 2020

You don't own me (Musings on questioning Dr. orders)

 Updated: March 1, 2020
February's blog derives from another TraQ case study from decades ago that discusses a topic not often included in online transfusion medicine cases but is still relevant. This case was based on a case study used to teach nurses at the McGill University Health Centre (MUHC) in Montréal, Québec. Because of this blog, I've revised the case to update all links. 
  • The blog's title derives from a 1963 ditty first recorded by Lesley Gore.
Case Study O6: Transfusion Reaction Coincidental with Failure to Disobey Physician Orders
This case was suggested by an RN and, because I'm not a nurse, several helped me with the case, also medical laboratory technologist pals from Hamilton and a physician (whom I taught when she was in Medical Laboratory Science at the University of Alberta). 

This case study presents a scenario in which a nurse did not follow several key transfusion protocols and procedures, including adhering to the time limit for transfusing blood, monitoring vital signs throughout a transfusion, and questioning orders that contradicted hospital policies and procedures.

It began when the nurse called the attending physician to explain the situation and charted the conversation as follows:
  • The Dr. was made aware; he ordered to continue transfusion even if it takes all day.
What happened to the patient? Based on laboratory results and a multidisciplinary discussion, staff concluded that a febrile non-hemolytic reaction had likely occurred after the second PRBC and had triggered subsequent events:
  • Increased temperature and chills increased intracranial pressure (the drain had been closed the previous day), leading to
  • Seizure and convulsions (treated by medication, induced coma, and intubation)
Analysis of the incident revealed that the nurse in question required remedial training related to resolving slow running transfusions and critical thinking in general, and also required re-training for how to monitor and document transfusions.

A more systemic problem was identified regarding the responsibilities and related skills of health professionals to provide checks for patient safety as part of the healthcare team. In other words, she should have questioned the physician's orders and taken it further, though that would be difficult.

Further analysis resulted in individual re-training and a system-wide education program on responsibilities and skills for providing interdisciplinary checks to ensure patient safety.

Key learning points include:
1. Clinical staff who administer transfusions must be trained and assessed in blood administration.

2. Monitoring and documenting vital signs must be done for each blood component transfused before, during, and after transfusion according to established policies and procedures.

3. Scopes of practice ensure that health professionals have the required education, training, and professional qualifications to perform their duties competently and safely.

4. Within their respective scopes of practice, members of the health care team collaborate in providing patient care.

5. Perceived loss of autonomy is considered to be a major obstacle to collaboration and open questioning within health teams.

6. Nurses and allied health care professionals such as medical laboratory technologists have a duty to question physician orders that are inappropriate or unclear.

Yes, I'm being facetious with the title and song, having some fun, but I couldn't resist. Decided to use the version with Bette Midler, Goldie Hawn & Diane Keaton as in the 1996 film, The First Wives Club. Yep, love these actors.
As always, comments are most welcome.

Case Study O6: Transfusion Reaction Coincidental with Failure to Disobey Physician Orders (Links are fixed) 

Davies C. Getting doctors and nurses to work together. BMJ 2000 Apr 15;320:1021-2. [Changed title]

Mancini ME. Performance improvement in transfusion medicine. What do nurses need and want? Arch Pathol Lab Med 1999;123(6):496-502.

Poerto G, Lauve R. Disruptive Clinician Behavior: A Persistent Threat to Patient Safety (July /August 2006, Patient Safety & Quality Healthcare)

Salvage J, Smith R. Doctors and nurses: doing it differently. The time is ripe for a major reconstruction. BMJ. 2000 April 15; 320(7241): 1019-20.