Published July 17, 2024
When it comes to keeping patients safe, family members are often highly motivated to make sure that the right treatments are provided to their loved ones. They can help catch potentially harmful events before they occur. They can even identify changes in their loved one’s condition early enough to prevent severe harm.
In 2019, ISMP published an article, Partnering with families and patient advocates: another line of defense in adverse event surveillance, for healthcare professionals. The article was about events that had been reported to ISMP where a family member or patient advocate noticed something unusual about their loved one. They told their concerns to a healthcare practitioner who took action and prevented the patient from being harmed. However, we continue to receive reports of practitioners not listening to patients, families, and caregivers when they speak up about safety concerns with medicines. In other reports, patients or family members provided important information to healthcare practitioners who did not share that information with others who needed it to take action and prevent harm.
Recent Event Reported to ISMP
The mom of a teenager told us about an event that could have harmed her child. The teenager has chronic health problems and has been getting intravenous (IV) (through their veins) nutrition at home for several years. During a hospital stay to treat an infection, the IV nutrition, which they were receiving at home, was stopped due to hospital policy.
The daily IV nutrition the teenager received at home contained a large amount of potassium because of the child’s health needs. Even though the mom told the doctor about the need for a higher dose of potassium, the doctor ordered regular IV fluids (with a lower amount of potassium) until the IV nutrition was ordered, prepared, and given to the patient.
During the second night, the patient’s mom noticed her child’s heart rate was really low. She spoke to the nurse since this was not normal for her child, but was told not to worry. A few hours later, the mom could not get her child to wake up and their heart rate was even lower. The mom asked the nurse to have her child’s potassium level tested. The nurse contacted the doctor who ordered a blood test to check the potassium level. The mother was right! Her child’s potassium level came back extremely low. The doctor then ordered a potassium infusion to be given right away. Within a few hours the teenager felt better, and their potassium level was back to normal.
Partnering to Protect Patients
Even though the teenager’s mom told the doctor her child needed higher doses of potassium, this important information did not seem to influence the child’s treatment plan which resulted in temporary harm. This event raises some questions: Why was the mom’s request to provide her child with their typical potassium dose ignored? Why was action not taken sooner when the mom told the nurse that her child’s heart rate was below their normal range? What might have been the outcome if the mom had not asked that the child’s potassium level be checked?
The total systems safety approach is a method many healthcare organizations are using to promote patient safety. This approach includes patients and families as active partners in patient care to reduce preventable harm.
Here’s what you can do: If you, a family member, or friend needs medical care, consider the following recommendations:
Other resources available for patients, family members, and patient advocates include the following:
