Zach Hoover was a 57 year-old man, who lived
in Montgomery, Alabama. He lived in a small 1-bedroom apartment with his cat Milo. During
the week he worked as a janitor in the local high school and on weekends he volunteered
at the local animal shelter. Zach’s only real splurge was a weekly bingo night that
he had been attending since his divorce finalized. One afternoon, Zach was cleaning the high
school yard, when he experienced weakness in his legs. Over the next few days, the weakness
gradually progressed until he was barely able to get around without the help of a cane.
One Friday evening he had had enough. He filled up Milo’s food bowl to the brim, zipped
up his jacket, and called a taxi to take him to the emergency room. When Zach arrived at the Emergency Department,
he was examined by a young attending physician, Dr. Tia Pearson. The conversation was slow
and meandering. Zach complained about how his weakness was affecting all aspects of
his life. “I live only a few blocks from here but I still had to take a taxi.” He
complained. Dr. Pearson listened carefully and questioned Zach more about his condition.
“Have you experienced any chest pain lately? Shortness of breath, headache, or vomiting?”
Zach said no. He was generally quite healthy, didn’t smoke, didn’t drink, and had even
stopped eating red meat and processed foods. On physical examination, the heart, lung,
and abdominal examinations were all normal. “Since your problem isn’t specific enough,
I want to run some blood tests and an ECG.” Dr. Pearson explained to Zach. He agreed and
after the tests were run, he waited patiently for the results. When lab results came in
they showed hyperkalemia – high potassium levels, so Dr. Pearson arranged for Zach to
get admitted to the hospital and started ordering some medications to help lower his potassium
levels. The nurses administered IV medication to treat the hyperkalemia, and got him ready
for his hospital admission. Within a few hours, another set of labs was
ordered – this time by Dr. Carr who was the doctor in charge of all overnight admissions.
When the results came back, Dr. Carr went into Zach’s room to wake him up. “Zach,
we reran your labs and this time the results came back completely normal. I’m a bit confused
but I want to stop your medications.” Zach didn’t understand “Doc, isn’t that good
news? Doesn’t that mean that the medications worked?” Dr. Carr responded “Well, your
potassium levels were extremely high and shouldn’t have corrected so fast. I want to draw another
set of labs right now to confirm what we’re seeing.” I looked at your original ECG which
also didn’t show any changes, so I’m wondering if the lab made a mistake here. Two hours later, Dr. Carr’s suspicion was
confirmed. The repeat labs were still normal and the lab had reported making a mistake.
The laboratory technician told Dr. Carr that a mistake had been made and that Dr. Carr’s
original blood sample was retested and that it did not show any evidence of hyperkalemia.
The medications that Zach got in the emergency room were unneeded and he could be discharged
home because everything looked normal. That night, another patient in the hospital
– Melina Sanchez suffered a cardiac arrhythmia. She had renal failure and her potassium level
had been creeping upward. Dr. Carr had ordered her electrolyte levels and they were normal.
It turned out that the mistake that the laboratory had made was that they swapped blood samples
for two patients – Zach Hoover and Melina Sanchez. Melina’s initial blood sample showed
hyperkalemia and that was reported under Zach Hoover. So while medications and IV fluids
were being given to Zach, Melina was quietly getting worse as her potassium levels drifted
higher and higher. 2 weeks later, Dr. Carr received a letter
stating that his hospital is being sued and that he’s being named specifically because
of his inappropriate management of Melina Sanchez. Dr. Carr had realized the laboratory
error, but didn’t notify the hospital to do an immediate root cause analysis so that
other patients at risk could be identified right away. Now – to rewind this back – let’s say that
Dr. Carr had alerted the hospital’s risk management team as soon as the laboratory
technician reported that a mistake had been made. The risk management team would have
looked into the exact nature of the mistake – did the lab misreport the result, did they
swap results, was the assay off – in which case many lab results may have been erroneous?
The team would have quickly gotten to the root of the problem to help ensure the safety
of other patients in the hospital. They would have found out that two results had been swapped
and alerted Melina Sanchez’s medical team about the mistake. If that had happened IV
fluids and medications could have been given to Melina Sanchez to potentially bring down
her potassium levels. The moral: When there’s a medical error, it’s important to notify
the hospital risk management and patient safety team so that they can analyze the error to
understand the cause and prevent it from recurring.