At the end of this activity, you will be able to:
• Describe how staffing shortages and inappropriate supervision can lead to adverse events.
• Identify contributing elements to a case resulting in the death of a patient.
A healthy 57-year-old man underwent a liver donation procedure. He began to manifest some tachycardia late on the second postoperative day. Early on the third post-operative day, he began to hiccup, and complained of being nauseated; later that day he was pronounced dead.
On January 10, a healthy 57-year-old man underwent a liver donation procedure that successfully resected approximately 60 percent of the right lobe of his liver in preparation for transplanting that liver into his brother, a 54-year-old man who suffered from a degenerative liver disease.
After what was described as a technically uneventful transplant, the donor patient seemed to do well on the first postoperative day. Late on the second postoperative day, he began to manifest some tachycardia. Early on the third post-operative day, he began to hiccup and complained of being nauseated. He was given symptomatic treatment. Later that day, he began to vomit brownish material. He became oxygen-desaturated and was placed on 100% oxygen by mask. He continued to vomit, aspirated, and suffered a cardiac arrest, from which he was not resuscitated; he was pronounced dead on the third post-operative day.
At autopsy, he was found to have aspirated bloody vomit in his lungs and Clostridium perfringens growing in several abdominal sites.
Three months later, the state health commissioner issued a 10-page report of an inquiry into the circumstances surrounding the patient’s death, offering the following reconstruction of the sequence of events:
• January 10—Patient undergoes surgery to remove the right lobe of his liver. No complications occur during the procedure.
• January 11—Patient is recovering; his condition is stable.
• January 12—Patient is “examined” during rounds by first-year transplant fellow and PGY 4 surgical resident. Transplant fellow neither looks at, nor asks for patient’s vital signs. At 4 pm, patient develops tachycardia.
• January 13—
Approximately 1am, patient develops hiccups and nausea. Patient is given medication to control symptoms, which may have masked the underlying problem.
At 8:45am, patient is examined by PGY 4 surgical resident who is unaware of the patient’s continuing tachycardia and nausea and previous hiccups and writes a progress note indicating vital signs are stable.
1:10 pm patient vomits brownish materials, tachycardia persists. PGY 1 surgical resident calls transplant fellow who is in a bookstore outside the hospital. He advises against insertion of a nasogastric tube. Upon returning to the hospital, and despite the patient’s distress, he does not examine him, but instead prepares a pre-operative work-up on another patient scheduled for surgery the next day.
2:00pm patient’s oxygen saturation is unacceptably low; 100% oxygen is administered by mask.
3:00pm nurse calls PGY 1 resident to inform her that the patient is continuing to vomit and has difficulty breathing.
3:10pm patient becomes unconscious after vomiting more brownish materials and frank blood. Code is called; resuscitation measures are unsuccessful.
3:40pm patient is pronounced dead.
TASK : liver donation procedure
DATE : 10 Jan 2016