arrest and pericardial window insertion, she developed right-sided pleuritic chest pain and relative hypotension. Two days earlier, based on the unlikelihood of recurrent pericardial effusion (with the pericardial window in place), the patient’s mediastinal drain was removed. Again considering the possibility of pulmonary embolism and in an effort to diagnose the patient, the residents initiated intravenous heparin and a repeat spiral CT scan. Later that same morning, the patient’s attending physician discontinued the anticoagulant medication. An emergency echocardiography revealed a large thrombus in the pericardium compressing the left atrium of the heart. The patient subsequently suffered a second cardiac arrest with pulseless activity while undergoing the echocardiography. An emergency sternotomy was performed; then the pericardial clot was evacuated and a laceration of the left ventricle was repaired. On the second day in the intensive care unit, the patient developed R-on-T phenomenon, followed by torsade de pointes tachycardia and subsequent pulseless ventricular tachycardia, requiring intubation, defibrillation, and amiodarone therapy. Laboratory results revealed the patient’s renal function and metabolic acidosis had worsened, requiring dialysis.

Although the authors indicate that the decision to discount tamponade and restart anticoagulation therapy may have been the worst decision of the case, it may be difficult even here to get a consensus opinion on whether the decision was an “error” and whether such a system error could be prevented under the circumstances. The authors suggest that the resident’s error is more likely from not knowing his own skill limitations and not seeking a competent supervisor to help in making the decision, which represents an important policy issue throughout health care. The patient eventually recovered and was discharged after a 27-day hospital stay, with more than $200,000 in hospital charges and the need for long-term dialysis.

Six Sigma

Virtua Health, a not-for-profit community hospital system in southern New Jersey, adopted Six Sigma in 2000 to achieve operational goals. One of its first six projects, conducted between January and June 2001, sought improvements and error reduction in anticoagulation therapy. Specifically, the hospital sought to reduce errors related to incorrect pump settings, incorrect use of pumps, delays in obtaining and reacting to activated partial thromboplastin time (aPPT), dosing errors, and mixing errors. Other QI activities, including RCA, failed to address the overall performance of the anticoagulation process in quantitative terms.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement