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• W2892050293 abstract "James Reason's Swiss cheese model coined in the 1990s for hazard prevention has been integrated into several disciplines for risk management including health care, aviation, transportation, and mining.1 Reason hypothesized that most adverse events can be traced to one or more of four failure domains: organizational influences, supervision, preconditions, and specific acts. The first three factors are considered “latent factors” that are potentially modifiable events that may lay dormant in weeks, months, or years leading up to the final event. When the layers of cheese (representing barriers and safeguards in the organization) develop holes (representing weaknesses or deficiencies in these barriers) that align, a dangerous “trajectory for accident opportunity” is set up.1 Inflammatory bowel disease (IBD) is a chronic condition requiring the use of potent immunosuppressants and biologics that place patients at risk of treatment and disease-related hazards. In this article, a case2 of treatment-related death in IBD is presented with an examination of the latent factors associated with the adverse outcome. A 42-year-old male presented to the emergency department with abdominal pain, worsening diarrhea, and a 10 kg weight loss. A flexible sigmoidoscopy confirmed deep ulceration consistent with severe Crohn's colitis. His admission C-reactive protein was 220 mg/L, and intravenous hydrocortisone was commenced. An on-call registrar, who was not part of his usual treating team, anticipated he would need to commence a thiopurine and requested the resident medical officer order a thiopurine methyltransferase (TPMT) assay unbeknown to the treating team. The benefits and risks of starting 6-mercaptopurine (6MP) were discussed with the patient, and 50 mg was charted the following day by the treating team registrar. By day six, the patient was deemed fit for discharge; however at discharge, he complained of ongoing abdominal pain that required the administration of buprenorphine and tramadol. He was reviewed by the intern, who was only in his second week of medical practice. A senior medical opinion was not sought regarding the significance of a C-reactive protein result that returned later that day at 100 mg/L. The patient was given a discharge summary addressed to the general practice without specifying the general practitioner (GP). The letter included instructions to “do a blood test in 2 weeks;” however, a pathology request form was not included. The GP was not contacted directly by the treating team for a verbal handover. The GP was asked to coordinate the discharge care of this patient as there was no IBD nurse to provide ongoing oversight. The patient saw the GP on three occasions after the discharge for a combination of worsening gut and mood symptoms. The GP stated that he had not received the discharge letter, and conceded he did not request to see the patient's copy of the discharge summary. The GP did however acknowledge that the patient had been discharged on new medications including 6MP. The GP admitted he knew the 6MP was a cytotoxic but was not aware that it required regular blood monitoring and had continued to re-prescribe the medication without any additional blood test results. Three weeks after discharge, the patient was found collapsed on the floor, with blood-stained diarrhea. At the emergency department, the patient was profoundly hypotensive from gram negative septic shock and pancytopenia. He deteriorated and died 4 days after his second presentation from multi-organ failure. Meanwhile, the TPMT result had been made available electronically 9 days after the patient's discharge. As there was no formal policy in place at the time for checking the enzyme activity before prescribing thiopurines, there was also no mechanism to acknowledge its receipt (the level was 0.04 nmol/gHb/min). This pathology result was noted first by an intern after the patient had represented in septic shock and then by the treating consultant and registrar after the patient had died. The issue of checking the TPMT result prior to the prescription of thiopurines is contentious; however, the outstanding problem in this scenario was that there was no mechanism for blood monitoring in the early days after discharge. The irony that the TPMT result was available, without the knowledge of the treating doctors was all the more poignant. On closer examination of the death, several contributory factors became self-evident. Firstly, there was no formal policy on blood monitoring and/or the confirmation of TPMT activity before thiopurine prescription. Secondly, the role of the IBD nurse acting in an oversight role for the patient is highlighted clearly, and as such, the appointment of one should be a priority for all IBD teams. Thirdly, communication was clearly absent firstly, between the treating team and the GP and secondly, between members of the treating team. Finally, personnel inexperience on part of the GP and intern meant that several missed opportunities for early intervention followed. Mortality in IBD specific to Crohn's disease or ulcerative colitis is slightly increased compared with the general population. Nonetheless, the incidence of a treatment-related death should be exceedingly rare.3 In this case, the gaping holes in the barriers and safeguards of the Swiss cheese model aligned: lack of an IBD nurse, lack of an immunosuppressant monitoring policy, lack of team communication, and personnel inexperience, which culminated in an avoidable death. The prevention of such a re-occurrence starts with the examination of our institutional barriers and safeguards. For the wider community of IBD physicians, setting societal recommendations for standards of care including the minimum IBD nurse to patient ratio will cement the foundation for advocacy in each institution, many still unstaffed by IBD nurses. Finally, the availability of local clinical practice guidelines on common “hazard issues,” for example, safe prescribing of immunosuppressants and management of pregnancy in IBD, may also better position the treating IBD team to feel equipped in preventing future clinical disasters." @default.
• W2892050293 created "2018-09-27" @default.
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• W2892050293 date "2018-09-01" @default.
• W2892050293 modified "2023-10-13" @default.
• W2892050293 title "Swiss cheese tragedy case study" @default.
• W2892050293 cites W2106973868 @default.
• W2892050293 cites W2149756969 @default.
• W2892050293 doi "https://doi.org/10.1111/jgh.14435" @default.
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