Pharmacist focused on improving patient safety after near miss with son

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The course of Allison Wells’ life changed the morning of May 29, 2014. That was the day her then three-year-old son, Logan, nearly died. Logan, who has a rare kidney disorder, experienced a string of medical errors but it was one near fatal error that changed everything.

While being prepared for a gastroscopy at Royal University Hospital in Saskatoon, Logan was connected to an intravenous (IV) bag containing more than five times the appropriate concentration of potassium chloride.

“All of a sudden, Logan is screaming, writhing and trying to rip his IV out,” said Allison, who works as a Regina Qu’Appelle Health Region (RQHR) pharmacist. “I looked behind me and saw the bag of potassium and knew immediately it was too concentrated. I have a screaming child, I’m wiping puke off of myself and him, and am telling everyone that this IV can’t be run.”

Failing to capture anyone’s attention, Allison locked her son’s IV, which stopped the toxic dose from flowing into his body.

“In no more than one minute, concentrated potassium would have stopped his heart. The only person who knew a mistake had been made was me.”

This incident was life-altering.

“Anyone who’s a parent can relate to not letting your kid out of your sight. After something like this, you’re in a constant state of hyper-vigilance.”

From that day forward, Allison has taken a different approach to her work, and to her life’s mission. Now her professional work and her volunteer work are focused on making our health care system safer, and patient- and family-centred.

Bringing smart pump technology to RQHR

The implementation of provincial “smart” infusion pump technology and of a standardized parenteral formulary is vitally important to Allison.

Infusion pumps are electronic devices used to deliver fluids, medications and nutrition to patients. Smart pumps differ from typical infusion pumps in that they are pre-programmed with a drug library containing drug dosing information. Should a clinician attempt to program the pump with the wrong dose, the smart pump has built-in safety features that significantly reduce the chance of errors reaching the patient.

A parenteral formulary is a drug resource/dictionary which helps guide health care providers on how to administer, monitor and watch for specific drug interactions/side effects when medications are given intravenously.

Allison represents RQHR on the implementation team overseeing this project. Her role is to work with pharmacists, nurses, and physicians across the province to standardize the library and help define concentrations and develop safe drug limits. This will provide a level of consistency within the province never before seen. The smart pump program is expected to be rolled out in RQHR in early 2016. The rest of the province will follow, with all health regions adopting the technology and equipment by the end of 2016.

If Logan’s IV had been connected to a smart pump the day of his surgery, the near fatal error would not have reached him and he, his family and his health care team would not continue to re-live those events to this day.

Stopping the Line to improve safety

In a volunteer capacity, Allison serves as a patient/family advisor on the committee overseeing the implementation of a “safety alert/stop the line” program in RQHR. This is part of a provincial initiative that intends to build a safety culture and make health care environments safer for patients, staff and physicians. The safety alert/stop the line strategy encompasses processes, policies, and behavioural expectations that support patients, staff, and physicians to be safety inspectors, to identify and fix potentially harmful mistakes in the moment, or to stop the line and call for additional help to restore safety.

“In my role, I’m helping ensure patients, families and staff are able to speak up and stop unsafe situations immediately. The goal is to prevent harmful situations from ever occurring.”

The team’s activities include developing protocols around the reporting of events where harm may occur. Stop the line is being trialed on a number of RQHR inpatient units in order to test and improve practices and processes. The provincial goal is to fully implement a provincial stop the line process throughout Saskatchewan by March 2018.

Allison is also helping set baseline expectations for patient and family centred care (PFCC) as an advisor on the Health Quality Council’s PFCC Guiding Coalition and has served on the board of directors of Hope’s Home, a daycare which provides care for children with complex medical needs, their siblings as well as typically developing children from the community.

Understanding patient-centred care

Allison said the medical error that nearly took her son’s life has given her a better understanding of what it means to deliver patient-centred care.

“As medical professionals, we don’t always understand what patient- and family-centred means. We do things for patients. Now, I do things with patients. I see health care from the other side.”

While she’s still recovering from this event, Allison said witnessing concrete changes in the health care system is helping her heal.

In response to Logan’s medical error, Saskatoon Health Region created a multidisciplinary improvement group to examine the root causes. The Region has since removed concentrated potassium chloride from acute care pediatric units. Now, when a commercially pre-mixed infusion is not available, the hospital pharmacy prepares the potassium chloride infusion in the required concentration and provides it to the unit in a ready-to-administer format. RQHR follows a similar process, which ensures appropriate patient-specific infusions are available when required.

Allison has replayed the fateful event in her mind hundreds of times and firmly believes that every health care provider involved was doing his or her best to care for her son. But, as she learned, good intentions are not enough. The health care system needs to be safety proofed.

“My ultimate wish is the metamorphosis of health care into a truly safe place for all our loved ones. We have a long way to go but we can all make changes every day to make this a reality.”

To learn more about Logan’s near miss, go to https://www.saskatoonhealthregion.ca/news/SaferEveryDay/Pages/Logan’s-safety-story.aspx

Photo credit: Evelyn Marcil

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