Nurses’ errors were found during an inquest to be largely to blame for the death of a 3-year old boy Aidan Mara. One of these was a fixation error and the coroner recommended that the phenomenon of fixation errors must be included in nurses’ training.
Aidan was admitted on July 27, 2014, at Sutherland Hospital, in New South Wales, Australia, severely ill from an Influenza A infection. By the morning of his third day in the hospital, he appeared to be more alert and interested in eating and drinking. His vital signs were nearly normal, and no longer showed signs of respiratory distress. He was still receiving oxygen via nasal cannula and was on an intravenous drip.
Aidan complained that he wanted to urinate and during doctors’ rounds, it appeared that Aidan did have a full bladder despite a urinary catheter being in place. His doctor advised that his catheter is removed. When his nurses removed the catheter a large amount of urine was expelled, and he also had a loose bowel motion. The boy was upset by the soiling.
The senior of his two nurses decided that it would be all right to remove the oxygen for a few minutes so that Aiden could have a shower. Apparently, the cannula had been removed earlier on in the morning so the boy could be weighed and he hadn’t shown any signs of distress. It appears that the decision to remove the oxygen had been made without much thought and that the boy’s doctor had not been consulted.
The nurses did not supervise Aiden in the shower. He was sitting on a chair most of the time while being held up by his father. In the end, he stood up briefly and then collapsed.
On returning him to bed, the nurses reattached the oxygen as well as the pulse oximeter. It appears that the nurse could not get a trace of either saturation or a pulse rate on the monitor. Believing the device to be faulty, another one was fetched. A saturation reading was obtained and at first no heart rate and then later a faint one.
Aiden’s father was out of the room during this time to attend to a phone call. When he returned, the nurses were still busy checking the monitoring equipment. Aidan’s grandmother pointed out to him that Aidan did not seem to be breathing. He alerted the nurses who checked the patient and immediately called the doctor. The emergency button was activated, but it was too late.
The time between Aidan’s collapse and the doctor being called was shown to be around 14 minutes. The coroner found that this was unacceptably long and that it was “as a result of the fixation on the monitoring equipment, which the nurses thought must be the cause of the failure to get adequate readings.”
“as a result of the fixation on the monitoring equipment, which the nurses thought must be the cause of the failure to get adequate readings.”
The nurses’ failure to observe Aidan’s clinical condition while focusing on the monitoring equipment is a perfect example of what is known as a fixation error. This type of error is well-described in the literature on patient safety. It happens when a person, or even a whole group, is caught up in a pattern of believing that there is only one possible solution to a problem or only one explanation for an occurrence. Awareness of the situation as a whole is lost.
You can learn more about fixation errors and how to overcome them in the article No simple fix for fixation errors: cognitive processes and their clinical applications.