A case's root cause analysis of osteofascial compartment syndrome induced by radial artery puncture and its defensive strategy

Feng-Ying Kang，Yang Yang，Yu-Ping Tong，Ya-Li Hu，Ning-Ning Xue

aResident Standardized Training Base，First Hospital of Shanxi Medical University，Taiyuan，Shanxi 030001，China

bEmergency Station，First Hospital of Shanxi Medical University，Taiyuan，Shanxi 030001，China

cCollege of Nursing，Shanxi Medical University，Taiyuan，Shanxi 030001，China

Original article

A case's root cause analysis of osteofascial compartment syndrome induced by radial artery puncture and its defensive strategy

Feng-Ying Kanga，*，Yang Yangb，Yu-Ping Tongc，Ya-Li Huc，Ning-Ning Xuec

aResident Standardized Training Base，First Hospital of Shanxi Medical University，Taiyuan，Shanxi 030001，China

bEmergency Station，First Hospital of Shanxi Medical University，Taiyuan，Shanxi 030001，China

cCollege of Nursing，Shanxi Medical University，Taiyuan，Shanxi 030001，China

A R T I C L E I N F O

Article history：

Received 22 January 2016

Received in revised form

12 February 2016

Accepted 23 March 2016

Available online 16 June 2016

Radial artery

Arteriopuncture

Osteofascial compartment syndrome

Root cause analysis

System defense

Objective：The objective of this study was to reduce or avoid the occurrence of the cases of osteofascial compartment syndrome induced by a radial artery puncture for arterial blood gas analysis.

Methods：We analyzed an adverse event using cheese model analysis，“fish bone”analysis，root cause analysis，and other methods.

Results：There are three root causes leading to an adverse event：operation technique，assessment of the disease，and informing patient families.However，there are many reasons to promote the occurrence and development of the event.

Conclusions：We should analyze and manage the adverse events in patients from the point of view of a system.Developing the measures of a system defense can enhance patient safety and create a good safety culture.

©2016 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license（http：//creativecommons.org/licenses/by-nc-nd/4.0/）.

1.Introduction

Arterial blood gas analysis is the most commonly used inspection means in the clinical assistant treatment of respiratory and circulatory system diseases.Through the analysis of arterial blood components，doctors can determine the condition of patients，treatment，and medication usage.An arterial puncture should be completed strictly in accordance with the standard operation.We should choose the puncture side without causing infection，arteriovenous embolism，and other problems.Meanwhile，we should choose the obvious position of pulsation as the puncture point.The radial artery，femoral artery，brachial artery，and dorsalis pedis artery are good choices.Complications，such as bleeding，hematoma，thrombosis，vasospasm，and infection，may occur when an artery is punctured.Research shows that1the puncture needle into the vein is the most important reason for failure to acquire arterial blood gas，but hemorrhage and hematoma are the most common complications of an arterial puncture.

One case that was diagnosed as osteofascial compartment syndrome occurred in the emergency department in the FirstHospital of Shanxi Medical University in August 2014.The patient was punctured in the radial artery for arterial blood gas analysis. Now，we will analyze the process and correlative factors of this adverse event to look for the root cause of this complication.

2.Methods

2.1.Case description

2.1.1.Key information

The patient was a 73-year-old male.He felt that he was being suffocated and was having difficulty breathing，so he went to a local hospital in the evening of August 8，2014.He was actually having an asthma attack.The doctors gave him antihypertensive drugs and remissed him with asthma.However，he did not feel any better，so he came to our emergency department accompanied by his family members and the 120 emergency workers for further treatment at 11：45 in August 9，2014.The patient had bronchial asthma for more than 10 years，and the disease would attack him in the winter of eachyear.In addition，he had a cerebral infarction more than 1 year ago.The patient had taken aspirin enteric-coated tablets for more than 1 year，once a day，and one piece at a time.The patient did not admit suffering from hypertension or any other disease（e.g.，diabetes mellitus）.Physical Examination：The patient was conscious.Blood pressure：150-160/100-110 mmHg；heart rate：130-150 beats/min；and blood oxygen saturation：90%-92%.Bilateral lung breath sounds were crude and wheezing was observed.Relevant examination：electrocardiogram showed that V2 and V3 showed an abnormal QS waveform.His blood biochemical examination showed that the creatine kinase isoenzyme（CK-MB）level was 19.4 U/L，and the troponin level was 1.39μg/L，which is above the normal range.Other blood examination-related parameters had no obvious changes except for the red blood cell count and hematocrit. The doctor diagnosed him with acute myocardial infarction，bronchial asthma，and cerebral infarction.

http：//dx.doi.org/10.1016/j.cnre.2016.06.007

2095-7718/©2016 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license（http：//creativecommons. org/licenses/by-nc-nd/4.0/）.

2.1.2.Key therapeutic measures and blood specimen collection

After the patient came to the emergency department，a doctor immediately performed a physical examination.At the same time，nurses gave him oxygen，performed dynamic electrocardiograph monitoring，and helped the doctor complete the related examination.After some related results returned，the doctor treated him by controlling his blood pressure and applied antiasthmatic drugs，anticoagulation therapy，and other symptomatic treatment.The patient had to be hospitalized for observation.During the 3-day observation period，his arteries were punctured three times for blood gas analysis because of his illness.Sampling time and sites were in the right brachial artery at 12：00 on August 9，in the right radial arteryat 23：00 on August 10，and in the right femoral arteryat 09：00 on August 11.Arterial blood samples were collected successfully.Before the femoral arterial blood sample was collected，one nurse collected venous blood from the lowerone-third dorsal side of his right forearm，which was not successful.At 04：00 on August 12，the patient complained of pain in his right forearm.Immediately，a nurse notified the doctor on duty.Physical examination showed that there was a red oncotic area about 5-10 cm on his forearm.The skin temperature of the injured area was lower than the normal temperature.His radial artery pulsed normally.The doctor considered that it may be puncture-site hematoma，and that using 20%magnesium sulfate wet dressing was applied on his forearm，which was thought might relieve the pain and swelling.At 05：50，the patient complained that he felt more pain，and the oncotic area enlarged to about 7-12 cm.His radial artery pulsed weakly.The doctor checked his blood vessels of the right forearm using the color Doppler ultrasound.However，some inspection facilities were found unavailable inourhospital，especiallyat nighttime，sothe doctorcomforted the patient by injecting Bucinnazine.Dosage of the drug is 100 mg. At 08：10，the doctor checked his blood vessels of the right forearm using the color Doppler ultrasound.The results showed that there was a diffuse hematoma in the right side of the forearm and an open wound on the vessel.His doctor advised to hemostasis by pressing the puncture site.Because his pain and the oncotic area continued to increase，a large consultation of doctors was organized at 11：00 on that day.He was diagnosed with osteofascial compartment syndrome，and then his forearm was operated on.（One circular laceration about 1 mm was found during the operation on his radial artery nearthe wrist dorsa.）Duringthe postoperative period，hewas taken to the intensive care unit.

2.1.3.Reasons

We consideredthatthe directreason for the patient's osteofascial compartment syndrome was due to the damage of the patient's dorsal radial artery from an arterial puncture by the nurse.In addition，there are other reasons to precipitate the occurrence and development of the accident.To clarify its essential reason and related factors for the occurrence of this special case，we hoped to find answers to alert nurses to operate according to standards and improve the management process usingascientific analysis method.

2.2.Research method

We had studied the process of osteofascial compartment syndrome using a root cause analysis（RCA）.A RCA is a retrospective analysis tool of an adverse event and a structured method to solve the problem.We can understand the process and causes of adverse nursing events with the help of an RCA.At the same time，we can find the root problem and solve it gradually.It is helpful to review and improve the management process.2RCA is a process to find out the potential or causal reason of an executive deviation.3This method focuses on aspects of the whole system and process improvement not just on an individual behavior review.4By analyzing the details of the process of the adverse events，we can understand the root causes of the incident through an executable program of the RCA.Then，we can take preventive measures to reduce the incidence of similar adverse events.5

2.3.Research process

One patient was diagnosed with osteofascial compartment syndrome due to a radial arterial puncture，which led to a surgical operation and a prolonged hospital stay.It brought severe injury to the patient，consistent with the standard of an RCA event.According tothe RCAexecutionprogram，6the first stepis to define the problem（Table 1）.

The second step in RCA execution program is to find possible causes.We can analyze the possible causes and the related factors leading to the adverse events by“fish bone”tools（Fig.1）.

According to the RCA execution program，the third step is finding the primary cause by the following diagram（Fig.2）.

The fourth step is to make the improving measures and the control form（Table 2）.

3.Results

The event was analyzed seriously.When collecting arterial blood the second time，the depth of the depth of the puncture needlewas toodeeptodamage the blood vessel on the other side in the right radial artery.At the same time，because the nurse could not assess his condition seriously，and his family did not pressure the punctured site in the right methods and time，the injured blood vessel was bleeding for a long time.After that，the nurse did not assess the puncture point，and collecting venous blood in the ipsilateral forearm using a tourniquet was unsuccessful.This behavior aggravated the damage to the blood vessel and hemorrhage.When the patient complained that his right forearm hurt，his family rubbed the punctured area and aggravated the bleeding. After informing his doctor，his problemwas not resolved in a timely manner，resulting in osteofascial compartment syndrome in his right forearm.The fundamental reasons for this adverse event are that the operative technique was not standard，and the assessment was not accurate.However，there are many factors to promote the occurrence and developmentof this event.Therefore，a strategyof a system defense needs to be developed.

4.Discussion

4.1.Occurrence of nursing errors are caused by a series of errors

James Reason，professor of psychology at University of Manchester emphasizes systematic concept of adverse events as a“Swiss cheese model”.6Each level of a defense system for defects or vulnerabilities is not able to intercept each other，resulting in the occurrence of“the final cumulative effect”and medical disputes.7This case illustrates this view.Reason6believed that，if a multi-layered defense system was established in an organization and all of the levels of the defensive system intercepted the vulnerability of each other，the system will be safe，although there is unsafe behavior for a single failure.Therefore，we should find out the root cause of this event，meanwhile，we make a defense system against the aspects of possible defects and loopholes.The fundamental measures for the prevention of similar incidents is the defensive strategy of a system.

Table 1 Problem description.

4.2.To make the defensive strategy of a system

4.2.1.To strengthen professional training and reinforce basic skills8The radial artery is the first choice for artery puncture because it is easy to operate on.The operator must fix the radial artery and feel the arteriopalmus along the artery.You can puncture the arterial pulse point vertically holding the injector in your right hand.Be careful to avoid puncture repeatedly and deeply.When you see the blood returning，you fix the injector and see that the artery blood is collected into the device automatically.When finishing the operation，you compress the puncture point correctly for 5-10 min to avoid the occurrence of a subcutaneous hematoma. Special caution should be given to the patients whose blood coagulation function is abnormal.When puncturing，the puncture angle should not be changed.It is appropriate if the depth of the puncture is the same to the inclined plane of the pinpoint.Of course，the depth is determined by the vessels.The time of the pressing should be extended to 15 min or more.The nurse should observe the puncture site at any time.Without bleeding，oncotic，and other special changes，it is good.When the brachial artery and femoral artery are punctured，the pressing time and pressing level should be increased accordingly.

4.2.2.To assess patient's condition seriously

First，the patient's condition should be assessed seriously before any operation.We should understand his disease's characteristics and risk.Attention should be paid to the patients whose blood coagulation function is abnormal.When puncturing，the nurse should try to be successful during the first try and avoid having to repeat the puncture.After puncturing，the nurse should press the puncture point for over 15 min until the bleeding stops.If the nurse is too busy to personally press the point，the nurse should then advise one practice nurse or a family member to apply the correct pressing method and pressing time.After puncturing，the nurse should do the missionary work well and tell the patient and his family members to avoid rubbing the skin around the puncturepoint.If the puncture site is uncomfortable，someone should promptly notify the medical staff.

Table 2 The control table of the improving measures.

4.2.3.To perfect the operation process

Perfecting the operating procedure of an arterial blood sampling is very important.First，disease assessment should be performed before the operation.Second，informing the family members about any potential risks and obtaining informed consent before the operation.In addition，the limitations of the inspection equipment in the emergency department cause individual diseases to go undiagnosed and to be treated in an untimely manner.It needs senior leader to coordinate and help provide some inspection equipment.

4.2.4.To take over from the first to last seriously

We should pay attention to the surface characteristics of the special patients and observe the sites of the puncture.In addition，we should observe the condition changes of a critical patient at any time.

5.Conclusions

RCA helps to find the root cause and improve our work.However，errors are difficult to avoid.We should focus on an area of medical care from the perspective of the system defense.The system tries to create an environment where errors happen infrequently.9With the development and application of high and new technology in clinical medicine and nursing work，the difficultyand the risk cause the nursing staff to increase the probability of error.10Lucian Leape，11a professor of the Harvard School of Public Health，put forward a viewpoint that the fear of retribution after a mistake is the only obstacle and biggest obstacle that hinders the development of patient safety in medical institutions today.Medical errors are mainly due to defects in our work system，such as the errors of design process，problem of task allocation，occupation training，and work environment.To reduce the incidence of errors，we must proceed from the system to correct.Domestic“blame culture”9hinders the development and improvement of medical safety.We should analyze and manage the adverse events of patient safety from the point of view of a system.To develop the measures of a system defense can enhance patient safetyand create a good safety culture.

Conflicts of interest

All contributing authors declare no conflicts of interest.

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How to cite this article：Kang F-Y，Yang Y，Tong Y-P，et al.A case's root cause analysis of osteofascial compartment syndrome induced by radial artery puncture and its defensive strategy.Chin Nurs Res. 2016；3：66-70. http：//dx.doi.org/10.1016/ j.cnre.2016.06.007

*Corresponding author.

E-mail address：kkangfy@hotmail.com（F.-Y.Kang）.

Peer review under responsibility of Shanxi Medical Periodical Press.