Anesth Analg 2007; 105:1511-1512
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000287019.57345.90
LETTER TO THE EDITOR
Clinical Protocols and Conditioned Human Behavior in the Background of Inadequate Information as a Risk Factor for Development of Critical Incidents
Raja Jayaram, MD, EDIC, and
Aji Mathew, FRCA
Central Manchester & Manchester Children's University Hospitals NHS Trust; Manchester, UK; icudr{at}doctors.org.uk
To the Editor:
Recently, a case report describing severe hypoglycemia in a diabetic patient undergoing dialysis utilizing icodextrin peritoneal dialysate was published in the Journal (1). We have also reported an episode of severe hypoglycemia in a patient, resulting from a different set of circumstances but that was accompanied by a similarly catastrophic outcome (2). In both of these cases, "tight" glycemic control in an intensive care setting contributed to the adverse outcomes. We have also reported the incidence of hypoglycemia in this context (3).
Any report of a critical incident is complete only if it is followed by a root cause analysis (4). Applying this principle, it can be shown that the root cause may have been the communication from the laboratory that the only accurate method for measuring blood glucose levels would be by central laboratory determination. However, the patient's own home glucometer (One Touch Profile; Lifescan, Milpitas, CA) is approved by the Food and Drug Administration to be used in her condition of diabetes with concomitant chronic renal failure requiring peritoneal dialysis with icodextrin. If the laboratory had communicated that any device except those working on glucose dehydrogenase pyrroloquinolinequinone is safe, then it might have led to a situation in which the intensive care unit staff would have used the patient's personal glucometer. This would have also averted the need to give an instruction calling for a deviation from routine practice in intensive care, i.e., bedside measurement of blood glucose, which carries the inherent risk of communication failure/violation because of conditioned human behavior. Hence the conclusions of the authors that to prevent similar catastrophic outcomes, only central laboratory determination of blood glucose levels should be obtained for endstage renal disease patients undergoing continuous ambulatory peritoneal dialysis needs modification. Also the editorial (5) reflecting on factors contributing to this incident calls for better communication and quality improvement initiatives in intensive care unit. At the same time it is also equally important to communicate the correct message.
Footnotes
Dr. Regli does not wish to respond.
REFERENCES
- Kroll HR, Maher TR. Significant hypoglycemia secondary to icodextrin peritoneal dialysate in a diabetic patient. Anesth Analg 2007;104:1473–4[Abstract/Free Full Text]
- Sinha S, Jayaram R, Hargreaves C. Fatal neuroglycopania due to accidental use of a glucose 5% solution in a peripheral arterial cannula flush system. Anaesthesia 2007;62:615–20[Web of Science][Medline]
- Jayaram RR, Hargreaves C. Strict glycaemic control in critically ill. Are we going overboard? Intensive Care Med 2006;32:S236
- Raja JR. Standards expected while reporting a critical incident. Anesth Analg 2007;105:8[Free Full Text]
- Wurz J, Regli B. In one ear and out the other: communication barriers as a risk factor for critical incidents. Anesth Analg 2007;104:1319–21[Free Full Text]
|
