Editorial: Strike Against Point of Care?
A Pennsylvania Department of Health report revealed that a patient died at a hospital after discrepant blood sugar results allegedly went unrecognized and, worse yet, unreported to doctors.
This post-transplant patient allegedly died as a result of low blood sugar for an extended period of time. The sad part is we wonder whether this tragic death may have been avoided with careful attention to detail and critical-thinking skills by nurses monitoring and caring for the patient.
But a critical question is “was this due to negligent point-of-care (POCT) testing?” The glucose strips used in the POCT equipment continued to produce high glucose readings in spite of ongoing insulin infusions and an injection of insulin. Regrettably, the laboratory staff had correctly reported very low glucose reading while these “high” results were being registered
at the bedside. The discrepancy apparently was either not recognized or just not reported to the
physician. Amounts of insulin continued to be administered and even increased. This decrease in glucose resulted in the patient eventually being brain dead.
The question that arises is whether this would have occurred if POCT was performed correctly? The strips, according to an article in The Morning Call, were “malfunctioning.” Aside from this fact, questions remain as to whether this was the result of operator error, lack of critical-thinking skills on the part of the practitioner or just plain user carelessness?
But where in the process did this flaw originate? Was the glucose strip to blame? Was it a lack of nursing staff POCT knowledge or critical thinking skills? Or, was the error attributable to the nursing workload?
My feeling is this probably resulted from a flawed communication system. POCT performed by nursing personnel has at times been considered outside the nursing scope of practice. This testing is difficult to monitor and small details often fall off the radar with a lack of attention. POCT is not only performed outside of the physical laboratory but more often than not outside of the laboratory umbrella. In reality, if only appropriately monitored, controlled and performed laboratory testing had been used to monitor the patient’s progress, he or she might still be alive today.
In this case, testing performed by the laboratory was accurate (or it appeared to be). Is this a case for elimination of POCT from the bedside testing arena? Or is it a call to arms for the laboratory to reclaim some of this billable testing and thereby provide more consistently accurate results? Will this incident cause a shift in the monitoring of this bedside testing?
Simply put, I don’t know. I don’t know what (if anything) will happen as a result of this incident, but I can surmise this is another reason for laboratorians to continue elbowing their way into a better place at the table when it comes to providing direction for patient care. We can only hope that medical errors like this serve as a wakeup call for all hospital personnel that failure to work as a team is no longer an option.
Furthermore, learning more about fellow healthcare practitioners’ professional duties coupled with being humbled by this unfortunate incident is definitely in order.
What do you think?