Zach Hoover was a 57 year-old man, who lived in Montgomery, Alabama. He lived in a small
1-bedroom apartment with his cat Milo. During the week he worked as a janitor in the local
high school and on weekends he volunteered at the local animal shelter. Zach’s only
real splurge was a weekly bingo night that he had been attending since his divorce finalized.
One afternoon, Zach was cleaning the high school yard, when he experienced weakness
in his legs. Over the next few days, the weakness gradually progressed until he was barely able
to get around without the help of a cane. One Friday evening he had had enough. He filled
up Milo’s food bowl to the brim, zipped up his jacket, and called a taxi to take him
to the emergency room.
When Zach arrived at the Emergency Department, he was examined by a young attending physician,
Dr. Tia Pearson. The conversation was slow and meandering. Zach complained about how
his weakness was affecting all aspects of his life. “I live only a few blocks from
here but I still had to take a taxi.” He complained. Dr. Pearson listened carefully
and questioned Zach more about his condition. “Have you experienced any chest pain lately?
Shortness of breath, headache, or vomiting?” Zach said no. He was generally quite healthy,
didn’t smoke, didn’t drink, and had even stopped eating red meat and processed foods.
On physical examination, the heart, lung, and abdominal examinations were all normal.
“Since your problem isn’t specific enough, I want to run some blood tests and an ECG.”
Dr. Pearson explained to Zach. He agreed and after the tests were run, he waited patiently
for the results. When lab results came in they showed hyperkalemia - high potassium
levels, so Dr. Pearson arranged for Zach to get admitted to the hospital and started ordering
some medications to help lower his potassium levels. The nurses administered IV medication
to treat the hyperkalemia, and got him ready for his hospital admission.
Within a few hours, another set of labs was ordered - this time by Dr. Carr who was the
doctor in charge of all overnight admissions. When the results came back, Dr. Carr went
into Zach’s room to wake him up. “Zach, we reran your labs and this time the results
came back completely normal. I’m a bit confused but I want to stop your medications.” Zach
didn’t understand “Doc, isn’t that good news? Doesn’t that mean that the medications
worked?” Dr. Carr responded “Well, your potassium levels were extremely high and shouldn’t
have corrected so fast. I want to draw another set of labs right now to confirm what we’re
seeing.” I looked at your original ECG which also didn’t show any changes, so I’m wondering
if the lab made a mistake here.
Two hours later, Dr. Carr’s suspicion was confirmed. The repeat labs were still normal
and the lab had reported making a mistake. The laboratory technician told Dr. Carr that
a mistake had been made and that Dr. Carr’s original blood sample was retested and that
it did not show any evidence of hyperkalemia. The medications that Zach got in the emergency
room were unneeded and he could be discharged home because everything looked normal.
That night, another patient in the hospital - Melina Sanchez suffered a cardiac arrhythmia.
She had renal failure and her potassium level had been creeping upward. Dr. Carr had ordered
her electrolyte levels and they were normal. It turned out that the mistake that the laboratory
had made was that they swapped blood samples for two patients - Zach Hoover and Melina
Sanchez. Melina’s initial blood sample showed hyperkalemia and that was reported under Zach
Hoover. So while medications and IV fluids were being given to Zach, Melina was quietly
getting worse as her potassium levels drifted higher and higher.
2 weeks later, Dr. Carr received a letter stating that his hospital is being sued and
that he’s being named specifically because of his inappropriate management of Melina
Sanchez. Dr. Carr had realized the laboratory error, but didn’t notify the hospital to
do an immediate root cause analysis so that other patients at risk could be identified
right away.
Now - to rewind this back - let’s say that Dr. Carr had alerted the hospital’s risk
management team as soon as the laboratory technician reported that a mistake had been
made. The risk management team would have looked into the exact nature of the mistake
- did the lab misreport the result, did they swap results, was the assay off - in which
case many lab results may have been erroneous? The team would have quickly gotten to the
root of the problem to help ensure the safety of other patients in the hospital. They would
have found out that two results had been swapped and alerted Melina Sanchez’s medical team
about the mistake. If that had happened IV fluids and medications could have been given
to Melina Sanchez to potentially bring down her potassium levels. The moral: When there’s
a medical error, it’s important to notify the hospital risk management and patient safety
team so that they can analyze the error to understand the cause and prevent it from recurring.