A patient death associated with the use of restraints is a “never event” as defined by the National Quality Forum (NQF). A recent death at a St. Louis, Missouri hospital has placed the hospital at risk of being terminated from the Medicare program after two other recent patient deaths associated with restraints and inappropriate patient seclusion.
In order to shed some light on the issues surrounding this most recent death, we can begin sifting through the facts in a root cause analysis. First, we enter the necessary information into the outline, including the impact to the goals (to view the outline, timeline and Cause Map, please click on download PDF above). The impacts to the organization’s goals begin the Cause Map, or visual root cause analysis. We can continue to add more detail to the Cause Map by asking “Why” questions.
We will then discover that the patient died of suffocation. An early concern was that the patient’s airway was blocked by gum, but the doctor determined that was not the case. (We can leave this cause on the Cause Map but can cross it out once it has been determined that it did not contribute to the incident.) The patient suffocated when she was left facedown on a beanbag chair, after being given a sedative that slowed her breathing, and was not properly monitored for breathing or a pulse. The patient had been restrained and sedated after threatening and assaulting the hospital staff. The patient was not constantly supervised, as suggested, possibly due to a lack of staff.
When the charge nurse arrived several minutes later and determined the patient was not breathing, resuscitation was not immediately begun (either mouth-to-mouth or CPR). She first left to get a light, then a stethoscope, then to find the patient’s nurse. After the patient’s nurse returned, she left to call a “Code Blue”. The first aide that arrived was told not to begin CPR or mouth-to-mouth because there was no breathing mask. She did anyway. Nine minutes later, the doctor inserted a breathing tube. The staff attempted to restart the patient’s heart but were unsuccessful and she was pronounced dead.
To determine what actions can be taken so that this never happens again, first we have to do a little more research into a few specific areas. First there needs to be a thorough investigation on the restraint procedure at this hospital. Because a patient died in restraints, some aspect(s) of the restraint procedure must be improved. To improve the procedure, however, first we have to know what the hospital staff actually did, step by step, in this case (and others). Then we should look at expectations and/or requirements for supervision of patients who are being restrained, or given sedatives, or who, based on their behavior, require constant supervision. For example, patients who are held facedown need extra supervision to make sure their breathing is not constricted. Additionally, it may be appropriate to turn the patient back face up once the sedatives begin to work.
The patient’s death was caused in part by the delay in resuscitation. Beyond the delay in recognizing the patient’s respiratory distress, the expectations for staff in this situation need to be addressed. Because the charge nurse was fired, it seems that the hospital did not think she properly performed her expected duties, but why? Perhaps the staff does not understand what they should do in this case, or doesn’t have the necessary equipment (such as a breathing mask) readily available. Although refresher training might be in order, we don’t stop there. We need to figure out all the things that are keeping our staff from being able to do what they need to for their jobs and remove those obstacles – BEFORE this happens again.
To view the outline, timeline and Cause Map, click on “Download PDF” above. To learn more about this incident, please see the news story.