Root Cause Analysis Simulation: Event Summary

A 31 year-old patient in the ICU required a PICC line insertion for IV fluids and medications. The patient was just starting to receive feedings through an NG tube that had been in place for a while and used for suction.

The IM resident inserted the PICC line. She ordered a chest x-ray to ensure the PICC line was in the correct position. The resident noticed the line was a bit too far in, and pulled it back about 4 cm. A repeat chest x-ray was ordered and completed. The resident reviewed the film and was satisfied with the position of the line.

The x-ray was read by the Radiology attending assigned to review the films from the previous night. On this particular morning, there were over 175 routine films in his queue. When he reviewed the patient’s x-ray, he noted that the PICC line was properly placed, however it appeared that the NG tube was located in the upper right quadrant of the lung. He called the ICU and told the nurse that answered that the patient’s PICC line was in the correct place and that the NG tube seemed to be positioned incorrectly.

The nurse answering the phone had been told the IM resident had ‘repositioned the tube’. She assumed that the resident was referring to the NG tube, and that he had already taken care of the problem. Because of this assumption, she did not did not convey the message to the resident.

The nurse increased the tube feedings. Shortly after, the patient’s O2 saturation began to drop. The resident ordered neb treatments and increased the O2.

Later that afternoon, the patient’s O2 saturation dropped to the low 60’s with wheezing. Tube feedings were stopped and a routine chest xray was obtained. Eight hours after the xray was taken, it was read. The result indicated ‘complete opacification of right hemithorax, with NG tube still in same position’.