Amanda Smith

Incident in the Cath Lab (Scene A)

Incident in the Cath Lab (Scene A) Program Transcript

DIRECTOR OF QUALITY CONTROL: The story you're about to hear is based on an actual event. A patient was injured as a result of a major medical error known as a sentinel event. The incident occurred in a cardiac catheterization laboratory. The Cath Lab is a separate hospital or community clinic department, where patients with coronary problems are sent by their attending physician for a variety of procedures, from imaging for diagnostic purposes to corrective surgical procedures. As with all invasive medical procedures there's always some degree of risk.

The major medical error unfolded this way. A 60-year-old female patient arrived at the Cath Lab. Her physician sent her there for diagnostic imaging to help diagnose a heart problem. After the usual intake procedures, the patient was taken to the lab operating room for her diagnostic procedure. But at some point, this woman was mistaken for another patient with a similar name, a patient scheduled for a stent placement to increase blood flow through her clogged coronary arteries. Instead of performing only a diagnostic imaging procedure on the woman, the Cath Lab team insert a stent in one for arteries. Shortly after, during her recovery phase in the lab, the woman suffered a debilitating stroke. The result was a total loss of speech and paralysis of her limbs.

The next day, the director of the Cath Lab was called to a meeting with me, the Director of Quality Control, to debrief about the incident. Rebecca before we get into what happened, I want to make certain we've intensified our care for this patient doing everything we can for her.

CATH LAB DIRECTOR: Yes, she's the ICU.

DIRECTOR OF QUALITY CONTROL: OK. Now I know you're somewhat new to running the Cath Lab here, but for me to hear about this case a full day after it happened, I should have been alerted right away.

CATH LAB DIRECTOR: sorry. We've just been so busy. Look, I can take you into the lab right now and you can see for yourself.

DIRECTOR OF QUALITY CONTROL: No. I get it. And I know you are, but with an incident like this you need to communicate with quality control right away. I assume you've communicated with the patient's family and with the lab staff about what happened. What have you told them?

CATH LAB DIRECTOR: Well, we thought it best to just say that the patient had suffered some complications.

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Incident in the Cath Lab (Scene A)

DIRECTOR OF QUALITY CONTROL: Complications. That's pretty vague why'd you say that?

CATH LAB DIRECTOR: Because I wanted to protect my staff and the hospital, or course, from a lawsuit or any bad publicity.

DIRECTOR OF QUALITY CONTROL: So, now that you're sitting here, it's just and I. I want you tell me what caused this error to happened.

CATH LAB DIRECTOR: Well, like I said, we had a busy patient load that day and I think it may be related to that.

DIRECTOR OF QUALITY CONTROL: You think. Well, what did your staff say? You should have had a department meeting to debrief and examine the incident in detail not only to find out what went wrong, but to devise a plan so it doesn't happen again.

CATH LAB DIRECTOR: haven't done that yet, but we will.

DIRECTOR OF QUALITY CONTROL: it soon.

CATH LAB DIRECTOR: will.

DIRECTOR OF QUALITY CONTROL: Is there anything else you haven't told me about this incident I should now?

CATH LAB DIRECTOR: The patient's husband is upset about what happened. He doesn't believe what I said about complications. So, he's hired an attorney and he has even called a reporter at the TV station and they've been calling me.

DIRECTOR OF QUALITY CONTROL: And you've been ducking them?

CATH LAB DIRECTOR: Look, I'm not a PR flack and I'm not about to start acting like one. What should I do?

DIRECTOR OF QUALITY CONTROL: You could start by communicating with the key players. My meeting with the Cath Lab Director expose numerous poor decisions about internal and external communications in the aftermath of the incident. Take a minute and identify the communications errors that you saw and submit a video response.

Incident in the Cath Lab (Scene A) Additional Content Attribution

© 2015 Laureate Education, Inc. 2

Incident in the Cath Lab (Scene A)

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