SHM Converge Scientific Abstract ePoster Gallery-Administration of Intrapleural Alteplase and Dornase Alfa: Patient Safety Case

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This case describes a patient safety event involving intrapleural alteplase (tPA) and dornase alfa, medications used to treat loculated pleural effusions and empyema in patients who are not surgical candidates. While effective, these are high-risk medications because complications can arise from both the drugs themselves and the administration process.<br /><br />The featured case involved a 63-year-old man with severe COPD, CAD, and tobacco history who was admitted after a fall with rib fractures. He later developed worsening hypoxia, was found to have an evolving empyema, and had MSSA on thoracentesis. After chest tube placement and initiation of the MIST II protocol, he developed worsening hypoxia and a drop in hemoglobin after the third dose. Blood drained from the chest tube after the tube was adjusted, and he was transferred to the MICU with a hemothorax.<br /><br />The harm event was traced to a process failure: staff did not turn the chest tube stopcock to allow drainage after medication instillation, so the intrapleural medication remained in the chest for 12 hours. Root causes included unclear roles, lack of a shared protocol, weak communication between physicians and nurses, reliance on verbal communication, EMR documentation gaps, and workload/staffing pressures.<br /><br />In response, Hines VA adopted a Standard Operating Procedure in May 2021 that includes an order set, policy link, and nursing instructions. Recommended action items are to define personnel and location for administration, develop a standardized policy and order set, ensure stakeholder education (physicians, nursing, pharmacy, and nurse managers), and teach the process to internal medicine residents, including formal chest tube training during MICU rotations.

Asset Subtitle

Megan Barnes

Meta Tag

Author List Megan Barnes

Category Clinical Vignettes

Concept Pleural tPA Administration

Concept Dornase alfa

Concept Loculated pleural effusion

Concept Empyema

Concept Standardized Policy

Distinguished Non-Finalist

Presenter Organization Loyola University Medical Center

Presenting Author Megan Barnes

Track Adult

Keywords

intrapleural alteplase

dornase alfa

empyema

hemothorax

chest tube

MIST II protocol

patient safety event

root cause analysis

standard operating procedure

medication administration error

Pleural tPA Administration

Dornase alfa

Loculated pleural effusion

Empyema

Standardized Policy