Into the Labyrinth of Nurses and Patient Safety

Physician treating a patient. Red-figure Attic...
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Lately I have begun to feel in need of Ariadne’s ball of string to help me find my way out of the labyrinth of the topic of nurses and patient safety. White papers, Institute of Medicine Reports, research-based journal articles, opinion pieces, various health policy and MD-blogs, patient-advocacy blogs, the Institute for Healthcare Improvement’s Improvement Map, the National Database of Nursing Quality Indicators. Lions and tigers and minotaurs, oh my! All very interesting in an information-overloaded sort of way. But they are also distractions—smoke screens. More interesting to me are what they aren’t saying.

Here are some things worth revealing and remembering. The US spends the most per capita on health care of any country in the world, yet ranks lower than Cuba on the Health Olympics in terms of health outcomes. According to the Kaiser Family Foundation, the US spent 2.3 trillion dollars in 2008 on all health care costs, and the largest portion of that (31%) was on hospital care. Physician and other clinical services accounted for another 21% of total health care costs. This should tell you, if you didn’t already know, that hospitals are big businesses. And especially big businesses are academic teaching hospitals, which besides the usual health insurance/public and private monies also receive large NIH, pharmaceutical/med device company, and other research monies. Many people contend that this fuels innovation and development of life-saving medical interventions for which the US can be proud. That may be true, but it comes at a cost, and not just at a monetary cost. In a JAMA article in 2000, Dr. Barbara Starfield from the Johns Hopkins University School of Public Health presented data to support the fact that the third leading cause of death in the US was caused by health care: iatrogenic causes including hospital and other medical errors. Not something that hospital administrators really want you to know.

Within the moneymaking world of the US hospital, nurses are not revenue-generators as are physicians—especially surgeons. Nurses have traditionally been viewed as passive functional doers within the hospital. Policy affects them; they do not affect policy. Nurses are blamed for medical errors. They are easy targets, being at the bottom of the hospital food chain.

A hospital oncology floor nurse (and writer), Theresa Brown wrote a NYT op-ed piece about this yesterday: “Physician, Heel Thyself.” She recounts an interaction she had with a hospital physician several months ago where he stated in front of a patient, ‘It’s a time-honored tradition—blame the nurse whenever anything goes wrong.’ And then he blamed her for the patient’s test result being late.

I even see this playing out in work by some of the highest profile patient advocates. For instance, look at the work of Sorrell King, the co-founder of the Josie King Foundation, a patient safety group based in Baltimore. In 2001, her 18-month daughter, Josie, died of medical complications at the Johns Hopkins Medical Center—the #1 rated hospital in the US for quality. Josie was admitted to the hospital with 2nd degree burns over 60% of her body and necessitated skin grafts. That these extensive burns were from the 18-month old “climbing into a hot bath” is not explained further. What I find amazing though is Sorrell King’s description of the incident, which she made in a speech to the Institute for Healthcare Improvement in 2002, and which is found on the Josie King Foundation website under “What Happened.” She blames the nurses for Josie’s dehydration and inappropriate methadone injection. She writes: As I sat with Josie, I noticed that the nurse on morning duty was acting very strangely. She seemed nervous, overly demonstrative and in a hurry. Uneasy, I asked the other nurses about her and they said she had been a nurse for a long time. Still worried, I expressed my concern to one of the doctors, and he agreed that she was acting a bit odd.

From publically available records of this event, there was the ‘usual’ cascade of systems-level issues contributing to Josie’s death. For instance, Josie had developed a central line infection, so her doctor’s had removed the line and she was no longer getting fluids except by mouth. Many different people including aides were recording Josie’s inputs and outputs of fluids, and they were recorded incorrectly. The ‘step-down’ pediatric unit Josie had been moved to was understaffed with nurses, and Josie had a temp agency nurse assigned to her. Josie’s doctors had hand-written an order to stop narcotics, but afterwards another doctor wrote an order to administer methadone. So the nurse followed doctor’s orders and gave the methadone. Perhaps she was acting strangely because she was a temp agency nurse and didn’t know the other staff members or the unit? Or she was trying to decipher conflicting doctor’s handwritten prescriptions and was afraid she’d get yelled at if she asked them for clarification?

The Josie King Foundation does many laudable things to try and improve patient safety, but from the materials available on its website, it perpetuates the “nurse blame game” culture. In addition, in the Foundation’s “Care for the Caregiver” program, it highlights the Nursing Journal, a therapeutic writing program for over-worked and stress-out nurses. Nice, but what does it do to change the culture of secrecy and blame that does little to promote quality nursing and patient safety?

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