Cardiology Fellow:
First Response: This was a really rough case. We just started having fellows as primary overnight on this service and this was my first rotation in fellowship. I’m still getting used to epic and it was a really busy admit night. I feel so bad that I ordered vanc for the wrong patient. I know doing multiple things at once definitely contributed to my error. I had this admission I was wrapping up, that’s who the vanc was supposed to be for, but I got paged about Mr. Bridges and jumped into his chart to put in some nursing orders. I think I must have just kept going and started putting in orders in on Mr. Bridges, not realizing I was in the wrong chart. I wish pharmacy would have caught it, but to be honest, they save my bacon all the time. I probably rely too heavily on them.
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Second Response: Well, my co-fellow signed out to me that night and said they had reached out to nephro in the afternoon as his PM BMP was worse and he was making very little urine. I assumed that they had relayed concern for increasing O2 needs and flash pulmonary edema especially because diuresis was being held. But I never spoke to nephro. I called the MICU pretty soon after my shift started as I was really concerned about his respiratory status and we were on the same page about transfer to MICU and need for HD tonight.
ICU fellow
First Response: Of course. I’m really upset about what happened. I remember being pretty concerned about how he looked when I saw him on the floor and accepted him pretty quickly. I didn’t speak to the nephrology fellow myself, I asked my intern to page them and tell them our concerns. I should have probably talked with them about how to do a consult since they were like 3 days into intern year. But we were really busy that night and I lost track of time until the patient began to decompensate. Once I realized HD orders weren’t in, I talked to my intern who told me nephrology said they would formally staff in the morning. I kicked myself at that point because I’m not sure the intern conveyed the urgency of HD needs to nephrology.
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Second Response: Yeah, I did it myself as I was prepping my intubation plan around 3am. They were very surprised he was being intubated- they thought he was stable when they were initially called and thought it was more of an FYI- for non-urgent HD tomorrow.
Nephrology attending
First Response: I’ve been thinking about this case for a while. I didn’t know they had transferred to the MICU that evening or that the patient needed HD that urgently. Although in hindsight, this was very busy service with a brand new 1st year fellow. I remember briefly hearing about this patient around 4 pm but we were running late and I said we can staff tomorrow if he was stable. Next time I heard about the patient was when I got a call around 4 am from my fellow saying he was intubated for hypoxia. That’s when I realized how serious it all was and that we had dropped the ball. I felt terrible.
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Second Response: Well I realized after debriefing with the fellow I never gave them clear instructions about how to manage after-hours care. I guess the fellow didn’t want to bother me when the patient first went to the MICU at 1130. I should have set communication goals at the beginning of the week. We will review this case at our division M&M and make sure we are transparent about what we want to be called about from now on.
Pharmacist
First Response: This was a really tough case! Thinking back about what could have happened- it was a super busy night and there were actually two patients with the same last name on the unit. I had a lot of others come in including for antibiotics and I must have verified vanc not paying attention to which patient it was.
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Second Response: Epic pops up with a quick alert saying GFR is this but it doesn’t actually make you say a reason you are dismissing the popup. It’s so easy to have alert fatigue and just click through without paying attention. I wish there was a system in place that forced you to put your reasoning for dismissing the alert, especially if there is a serious risk like a very abnormal creatinine. Also there is no safeguard for letting you know there are multiple patients with the same name on the unit.