PA PSRS Patient Saf Advis 2007 Sep;4(3):105-6.
The Big Picture
Critical Care; Nursing; Nutrition; Pharmacy
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Janet Johnston, RN, MSN, JD

Janet Johnston, RN, MSN, JD
Patient Safety Analyst
Pennsylvania Patient Safety Reporting System


Jan Johnston was the first nurse analyst hired for PA-PSRS. She is a registered nurse with a Master of Science in Nursing. She also has a law degree. Prior to joining PA-PSRS, she was the risk manager of a hospital system in New Jersey. She has reviewed tens of thousands of the reports submitted to PA-PSRS and written more than 30 articles for the Advisories. She has provided tremendous expertise and insight to the PA-PSRS team. She and her husband are retiring and moving to their vacation spot in Vermont. The PA-PSRS team is very appreciative of her dedication and contributions to patient safety in Pennsylvania. Prior to her departure, we asked Jan to give us her general impression of patient safety in Pennsylvania. The PA-PSRS team will miss her wisdom and wishes her a well-deserved retirement looking out her big picture window over the autumn leaves of Vermont.
John R. Clarke, MD, Editor

The Big Picture

As a clinical analyst over the past three years, I have had the privilege of reviewing thousands of Serious Events and Incidents submitted to PA-PSRS since its inception in June 2004. It has been quite an exciting experience seeing the program grow to a database containing nearly 600,000 reports.

Upon my retirement, I’d like to share one concept about these adverse events and near misses — a very common thread that runs through many of these reports. It has to do with what I call “The Big Picture.” It seems that many medical errors may occur because in performing individual health-related tasks we may not see how these tasks contribute to the patient’s condition as a whole. It’s sort of like having a bunch of jigsaw pieces in a box before we put them together to reveal a beautiful landscape. Each piece separately does not reveal the whole. And without each puzzle piece, the picture is not complete — we’re missing something. In healthcare, each task is very important to the patient’s care. However, if we do one task without seeing how it relates to the other tasks ordered for a patient, we may miss something vital, compromising the patient’s safety.

Here are some PA-PSRS reports that, I believe, highlight this point.

A diabetic patient was NPO after midnight as ordered for a diagnostic test the next day. The patient received insulin as ordered the next morning, went for the diagnostic test, and became hypoglycemic, requiring administration of D50.

An 80-year-old patient was ordered intravenous (IV) fluids at 250 cc/hr. This order was fulfilled for three days, at which time the patient was diagnosed with congestive heart failure.

A child who had a documented allergy to dairy products received a tube feeding of 100% whey as part of a protein tolerance test for renal function. The child sustained a life-threatening anaphylactic reaction.

A patient was on an Integrelin drip [blood thinner] after a cardiac catheterization. Overnight, the patient developed hemoptysis, and blood continuously oozed from the groin insertion site. The nurse documented detailed assessment notes and frequently monitored the patient. The nurse notified the resident. There were no new or revisions in orders. The next morning, the cardiologist saw the patient, stopped the Integrelin infusion, and ordered a sandbag on the groin after the Angio-Seal™ was discontinued.

Healthcare workers do not come to work intending to do a bad job. However, there are times when there is so much to do for so many patients that we become task oriented — writing orders or following orders without always considering whether such interventions are really appropriate in the context of the individual patient’s diagnosis, co-morbidities, and condition. Our clinical director, Dr. John Clarke, has called the process of putting the pieces together sense making, or situational awareness. This process could also be called holistic thinking, or “the big picture.” What systems or process breakdowns might have occurred to cause the errors specified above?

  • Why was the NPO patient’s insulin order not adjusted to prevent hypoglycemia?
  • Did it make sense for an elderly patient to have such a large amount of IV fluids for several days?
  • Does it make sense that a hospitalized patient receive no medications for several days?
  • Why was the dairy allergy not linked to the ingredients of the tube feeding that was ordered and administered?
  • Why would Integrelin (a blood thinner) be administered to a patient who was actively bleeding?

Adding systems and processes that incorporate a holistic perspective for each patient, rather than the tunnel vision of performing specific tasks, might enhance patient safety. Is there a way to formalize or standardize the process of seeing the big picture for each patient during the following situations:

  • With every new order/set of orders?
  • At change-of-shift report?
  • Whenever handoff communication occurs?
  • During multidisciplinary patient rounds?
  • During development and revisions of patient care plans and/or the medication administration record?
  • Whenever a patient’s level of care changes?

I am providing this food for thought in hopes of promoting dialogue. Maybe you have additional ideas about this subject. If so, please share them with the Patient Safety Authority through the PA-PSRS Help Desk at 866-316-1070 or so we can publish them in the PA-PSRS Patient Safety Advisory.

I am so proud of all the facilities, staff, and Patient Safety Officers who have made PA-PSRS a reality and such a success. Keep up the good work! I know Pennsylvania will continue to be in the forefront of patient safety, as a model for the United States and around the world.


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