How a Medication Error Killed My Grandpa

Would "No Interruption Zones" Prevent Such a Tragic Outcome?

My Grandpa was one of my heroes. He had survived WWI, the Great Depression, and WWII, and yet, he still wore a smile on his face everyday. And he loved his grandkids, and his great grandkids.

I was taking the second part of the boards one day when the dean came into the auditorium and pulled me outside.

She said, “your grandpa has been in an accident. He’s over at St. Mary’s. Go to him and we’ll worry about this test later.”

I had just finished a cardiology rotation at this hospital and one of my professors was Grandpa’s cardiologist. This gave me a sense of hope that Grandpa would be OK.

My professor said, “your Grandpa has a pneumothorax (a collapsed lung); they put in a chest tube to reinflate it; his heart failure is stable; we fully expect that he will make a full recovery.”

I was so grateful my Grandpa had a good prognosis.

The next several days went off without a hitch, but then … three days later my professor called me aside, and he had a grave look on his face.

He said, “your Grandpa’s blood pressure dropped to critical levels during the night. His kidneys have already started to fail. His blood pressure dropped because he received too much medication in his nitro patches.” I thought to myself, Patches? Plural?

He went on to say, “when the nurse was changing your Grandpa’s Nitro-Dur patch (nitroglycerin), she put on a new patch, but failed to take off the old patch. It was too much nitroglycerin for your Grandpa and his blood pressure dropped, and now his kidneys are failing.” I was devastated. The nurse was distraught. My Grandma and Mom were devastated. It was a feeling I still can’t put into words other than it was the worst feeling in the world.

Here was an institution that I trusted; a hospital where I was being taught how to be a physician; the hospital where I was born; yet it was this very institution that would take my Grandfather from me – from all of us.

Grandpa died several days later – all because of a mistake – a medical error – an accident. I’m still not quite sure what to call it. This happened more than 30 years ago. BUT, the VERY SAME mistakes, CONTINUE TO OCCUR in hospitals across our country! And this is senseless. These mistakes can be prevented by something we have learned from our aviation colleagues – it’s called The Sterile Flight Deck.

Healthcare organizations have translated The Sterile Fight Deck into NO INTERRUPTION ZONES. It’s just what the name implies. Certain critical activities are identified as no interruption zones. The most popular examples are medication preparation and medication administration. I’ll have more on NO INTERRUPTION ZONES in a post next week.

no interruption

I still have nightmares about my Grandfather’s death. I can still see the hallway where those difficult conversations took place, the waiting room where our family had to wait, and the wonderfully precious smile on my Grandpa’s face every time I went into his room. I ….

We didn’t know then what we know now. If we did, my Grandpa wouldn’t have died that week. But we do know what to do (implement no interruption zones) and what not to do (distract caregivers during critical tasks) so there really is no reason for errors that are caused by distraction. It also seems that every organization in the country, must immediately (if you haven’t already) IMPLEMENT NO INTERRUPTION ZONES in appropriate areas. When you do, I know you’re going to spare someone’s family from experiencing a similar life ending tragedy.

Please join me in this fight on behalf of our patients. Make patient safety your number 1 priority today and everyday. And sign up for my email newsletter where I’ll be sharing patient safety tools every week.

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