Fatal Error in Neonate: Does "Just Culture" Provide an Answer? - AHRQ WebM&M: Case & Commentary

Pediatrics | June 2010 | SPOTLIGHT CASE
Fatal Error in Neonate: Does "Just Culture" Provide an Answer?
Commentary by Sidney W.A. Dekker, PhD

Case Objectives

Describe the just culture approach to investigating errors in health care.
Analyze system contributions to errors in care.
Identify best sources of information for designing a response to an error.
Distinguish accountability for failure and learning from failure.

The Case

An infant was born prematurely at 30 weeks weighing only 1.8 kg. In the neonatal intensive care unit, he was started on total parenteral nutrition (TPN) with Premasol amino acid solution at 3 g/kg/d and dextrose 12.5%, 5 mg/kg/min. After being maintained using those solutions for the first 2 days after delivery, the care team added lipids on day 3. This was ordered as lipid emulsion 20% at a rate of 0.19 mL/hr.

The neonatal intensive care unit had frequent orders for this treatment and kept a stock of lipid emulsion on site. This practice avoided the delay between ordering, sending the order to the pharmacy, and waiting for the pharmacy to dispense the new TPN solution.

Within 4 hours of beginning the lipid emulsion administration through the TPN line using a smart pump, the infant's condition worsened. He showed signs of respiratory distress, pulmonary hypertension, coagulopathy, and liver failure. Soon after, the infant suffered a cardiac arrest and died.

As the symptoms displayed by this premature infant suggested lipid overload, the dose and rate of administration of the lipid formulation were assessed. Assessment revealed that the pump was set to deliver 19.0 mL/hr. In the process of calculating the dose with the concentration of lipid emulsion available on the unit, the RN had erroneously set the pump to deliver 100 times the ordered dose of 0.19 mL/hr. Upon discovery of the error, the nurse involved was fired by the hospital and her license was revoked. The sequence of events and underlying reasons for the error were not investigated further.

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