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Preventing Sentinel Events Caused by Family Members

Wall, Yolanda PhD, RN, BC, OCN; Kautz, Donald D. PhD, RN

Dimensions of Critical Care Nursing: January-February 2011 - Volume 30 - Issue 1 - p 25-27
doi: 10.1097/DCC.0b013e3181fd02a0
Leadership DIMENSION

As long as there are human beings involved in health care, there will be errors. Sometimes these errors are minor, and some can lead to significant morbidity and mortality. At times, the errors are caused by family members who mean well, but may cause further problems and possibly death. This article discusses as few case studies, potential errors, and strategies critical-care nurses can use to prevent these errors.

Errors are bound to occur in any field that involves humans. This article describes nursing interventions to prevent families from making deadly errors.

Yolanda Wall, PhD, RN, BC, OCN, is assistant professor of nursing at the University of North Carolina, Greensboro.

Donald D. Kautz, PhD, RN, is associate professor of nursing at the University of North Carolina, Greensboro. Dr Kautz also serves as a reviewer of manuscripts for DCCN.

Address correspondence and reprint requests to: Yolanda Wall, PhD, RN, BC, OCN, UNC-Greensboro, PO Box 26170, Greensboro, NC 27402 (

The night started as a typical shift. After getting report, the nurse supervisor started to make the rounds. For some reason, maybe intuition, the first unit she visited was oncology. As she turned the corner, she saw nurses on the unit frantically working on a patient. As she was getting ready to ask what was happening, she heard the code bell ring and then heard code blue announced overhead. This code was different, however, because it was cancelled before it began. The family decided to change the patient's code status from full code to do not resuscitate (DNR). Then, right after the code was stopped; the son approached the physician and asked if his sister could have caused their mother's death. The son and physician returned to the room and told the physician what had happened.

It was shift change, and the nurses were in report. His mother was receiving a breathing treatment, and the tubing attached to the mask became disconnected. Not wanting to bother the staff, his sister tried several times to reconnect the line. She was having trouble, but she finally was able to reattach the tubing to the line. However, it was the wrong line. She inadvertently attached the tubing to the peripherally inserted central catheter (PICC) line. Her brother had sat there and watched this happening. Their mother's condition immediately changed, and nurses were called into the room.

Hearing his story, the physician, the staff, and the nursing supervisor went numb. The patient, who had cancer, was stable and projected to go home soon. She was now dead at the hands of her own daughter. This death was a medical examiner (ME) by law case. The ME ruled the patient's death an accident due to air in the PICC, leading to an air embolism. The police were notified, and an investigation was started. The daughter was not prosecuted. The police concurred with the ME that the death was an accident; however, the family and especially the daughter will have to live the rest of their lives knowing that she caused her mother's death. The nursing supervisor was amazed that the oxygen tubing could be attached to the PICC line, but upon further examination discovered that it was possible.

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Even though this patient died on a oncology unit, similar events could happen in any units but especially in critical-care settings. A great deal of literature supports open visiting hours for the families of patients in critical-care units. Yet there is very little in the literature to help nurses in the rare event that a family member in advertently causes either a major complication or death in a critical-care setting.

Even minor errors in administering medications might cause severe discomfort. In one known incident, a patient drank a bottle of hexachlorophene (Phisohex) scrub the nurse brought in and left on the bedside table while she went out to get a bathing basin. This was not lethal, but it did cause abdominal discomfort and diarrhea. Major errors, on the other hand, could lead to death. If a family member grabbed a 10-mL syringe rather than a 1-mL syringe, a patient might get 300 U of insulin, rather than the prescribed 30 U. Giving too much warfarin to a patient who already has too high prothrombin time could lead to internal or rectal bleeding that is not detected in time to take action. Administering potassium chloride intravenous (IV) push, rather than diluting it in a 1000-mL IV bag, is likely to lead to deadly dysrhythmias. Flushing a PICC line with heparin that comes in 10 000 U/mL (meant for hemodialysis lines) rather than the normal heparin flush, which is 100 U/mL, may lead to internal bleeding or a hemorrhagic stroke. Keep in mind that errors are not limited to medications.

Just as the sister in the vignette somehow attached the oxygen tubing up to the PICC line, family members can make other mistakes that are deadly. A family member might remove the entire tracheostomy apparatus, instead of just the inner cannula, and then not be able to reinsert it, leading to respiratory distress and death. If a nasogastric tube feeding becomes dislodged, a family member might reinsert it into the airway and start the tube feeding, leading to aspiration. A family member might adjust the oxygen level and give too much oxygen to chronic obstructive pulmonary disease patients. In an attempt to silence alarms on IV pumps, a family member might hit the wrong button, giving too much medication, such as morphine and chemotherapy drugs to patients.

The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) outlines several additional possibilities, including connecting IV infusions indwelling Foley catheters or nasogastric tubes, external dialysis catheters, ventriculostomy drains, epidural lines, or the port of a pulmonary artery catheter.1 Clearly, any time one tubing can be physically connected to another, it is possible to make an error.

Unfortunately, there were no articles found in the literature to assist nurses in preventing families from making these errors, and thus, evidence on how to best prevent these errors is also lacking. The JCAHO defines a sentinel event as an error that has the potential to lead to or actually leads to an unexpected death or serious physical or physiological injury.2 The JCAHO encourages root-cause analysis to identify factors that lead to sentinel events and to voluntarily provide reports of these events to the JCAHO.1 Unfortunately, the JCAHO does not distinguish between sentinel events that are caused by family and those caused by staff. In 2006, the JCAHO issued a Sentinel Event Alert for tubing misconnections, even though these events are quite rare.1 This alert led to several articles in nursing journals encouraging facilities to adopt recommendations to prevent these errors. However, the focus of the Sentinel Event Alert and the other nursing articles was to prevent staff from causing harm from tubing misconnections with very little focus on the family. The only reference to families was the recommendation to "inform nonclinical staff, patients, and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions."1 (p2)

The Joint Commission International 2007 annual report did identify "avoiding catheter and tubing misconnections" as one of its 9 patient safety solutions, but again there was no focus on preventing families from making these errors.2 It is true that many of the recommendations to prevent staff from making mistakes could also prevent families from making the same errors. In a recently published position statement to prevent enteral feeding misconnections, the only mention of family was "to train nonclinical staff and visitors not to connect lines, but seek clinical assistance instead."3 (p389) This advice is contrary to the fact that even experienced, expert staff nurses have made these errors. Simmons and Graves4 noted that a nurse with 15 years of experience, high performance evaluations, and rating by his/her peers as an "expert" in managing stressful patient care situations inadvertently connected a feeding tube of expressed breast milk to an IV line in an infant. The misconnection went unnoticed until another nurse, responding to the IV alarm that the infusion was complete, discovered the error. In this case, the infant sustained no harm. Occurrences like these may be more often than is thought, because they may go unnoticed by the patient and staff.

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This case scenario and other errors related to family interference with patient care can be avoided with effective nursing interventions. Family education is certainly a first place to start. A national education campaign with a catchy slogan, similar to the "Call: Don't Fall" slogan to prevent falls could provide a slogan such as the following: "Resist the urge to assist: Call the nurse first" or something similar. In addition, the following nursing interventions should be implemented routinely:

  • Assess the family's understanding of the hospital and hospital policies.
  • Educate the family about the importance of calling for assistance.
  • Post signs on the door and on a chalk or white board in the room to call for assistance.
  • Make sure the unit secretary notifies staff immediately about call bells.
  • Institute hourly rounds, and be sure to check in with the family as well as the patient. Check the patient more frequently if needed.
  • Before breaks and lunch, arrange for another nurse to check rooms.
  • Do walking rounds when giving report to the on-coming shift.
  • Take turns giving report to the on-coming shift to make nurses available during shift change.

Although it is recognized that many of the above measures have been used by nurses, it never hurts to be reminded. Evidence that quality, patient safety, and risk management are essential to reduce possible errors. It is imperative that, as nurses, we receive the education we need to keep our patients safe. These nursing interventions will need to be tested for evidence-based practice. Research is needed to identify effective nursing interventions so that these types of events become a concern of the past. As Florence Nightingale wrote in 1863, "It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm."5 (p.iii)

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The authors thank Elizabeth Tornquis for editorial assistance and Qi Qin (graduate student), and Ms LaToya Winslow for their assistance with this manuscript.

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1. Joint Commission on Accreditation of Healthcare Organizations. Sentinel event alert. Tubing misconceptions-a persistent and potentially deadly occurrence. 2006(36). Accessed December 8, 2009.
2. Joint Commission International, 2007. Annual report. Partnering for better outcomes. www.jcinc.common/pdfs. Accessed December 8, 2009.
3. Guenter P, Hicks RW, Simmons D, et al. Enteral feeding misconnections: a consortium position statement. Jt Comm Qual Patient Saf. 2008;34:285-292.
4. Simmons D, Graves K. Tubing misconceptions-a systems failure with human factors: lessons for nursing Practice. Urol Nurs. 2008;28:460-464.
5. Nightingale F. Notes on Hospitals. 3rd ed London, UK: Longman, Green, Longman, Roberts, and Green, 1863.

Errors; Family members; Prevention of errors; Sentinel events

© 2011 Lippincott Williams & Wilkins, Inc.