Peter J. Pronovost, MD, PhD; Albert W. Wu, MD, MPH; J. Bryan Sexton, PhD
Grant Support: By the Agency for Healthcare Research and Quality (grant number U18 HS11902). Funding for the Quality Grand Rounds series is supported by the California Healthcare Foundation as part of its Quality Initiative. The authors are supported by general institutional funds.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Peter J. Pronovost, MD, PhD, Quality & Safety Research Group, Johns Hopkins University, 901 South Bond Street, Suite 318, Baltimore, MD 21231.
Current Author Addresses: Drs. Pronovost and Sexton: Quality & Safety Research Group, Johns Hopkins University, 901 South Bond Street, Suite 318, Baltimore, MD 21231.
Dr. Wu: Johns Hopkins University, 624 North Broadway, Hampton House, Room 633, Baltimore, MD 21205.
Pronovost P., Wu A., Sexton J.; Acute Decompensation after Removing a Central Line: Practical Approaches to Increasing Safety in the Intensive Care Unit. Ann Intern Med. 2004;140:1025-1033. doi: 10.7326/0003-4819-140-12-200406150-00013
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Published: Ann Intern Med. 2004;140(12):1025-1033.
“Quality Grand Rounds” is a series of articles and companion conferences designed to explore a range of quality issues and medical errors. Presenting actual cases drawn from institutions around the United States, the articles integrate traditional medical case histories with results of root-cause analyses and, where appropriate, anonymous interviews with the involved patients, physicians, nurses, and risk managers. Cases do not come from the discussants' home institutions.
A woman with metastatic cancer was hospitalized in the intensive care unit (ICU) for management of congestive heart failure and acute-on-chronic renal failure. The nephrology service initiated continuous venovenous hemodialysis through a large-bore catheter inserted in the right internal jugular vein. Two weeks later, a first-year renal fellow removed the catheter while the patient was seated upright in a chair. The patient became acutely hypoxemic and appeared to seize. Head imaging revealed global central nervous system ischemia suspicious for hypoperfusion.
Kenneth K Kessler
University of Miami School of Medicine
July 9, 2004
Focused Analysis of Medical Errors
TO THE EDITOR: Pronovost, Wu and Sexton (1) present an excellent in depth analysis of a medical error involving removal of a central line. Despite the value and increasing use of root cause analyses and system solutions to medical errors, it is often useful to determine the one person or circumstance that is "responsible" for the error, not to assess blame but rather to identify a focal point for future prevention. In this case the habit of dumping the "scut work" "“ routine removal of a catheter "“ on the least trained person appears to be pivotal. This seems lost in the analyses and "system factors" as summarized in the complexities of table 2. Clearly the person who assigned the first year fellow the task of removing the catheter without appropriate instruction is responsible. While system analyses may determine what fail-safes could have prevented inappropriate action and resultant harm, it is important to determine and specifically address the lynchpin of the system.
1. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004;140:1025-1033.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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