RCA Spurs Automated E-notification of Abnormal Lab Values

An article in the October 2012 issue of BMJ Quality and Safety describes how a root-cause analysis (RCA) of an adverse event involving miscommunication among three medical teams led one hospital to implement automated electronic notification regarding abnormal laboratory values. A 51-year-old patient with a history of testicular cancer was transferred from another hospital with mental status changes and weakness on the left side. Several hours after an elective stereotactic brain biopsy, the patient was found unresponsive and gasping. Computed tomography revealed a massive intracranial hemorrhage. Comfort care was begun, and the patient died the next day. It was discovered that the patient’s partial thromboplastin time (PTT) was markedly high two days before surgery, although it was normal four days before surgery. Neither the neurosurgery service nor the anesthesiologists were aware of the abnormal value before surgery. In addition, the patient’s prophylactic heparin was not discontinued as requested by the neurosurgery service.