Tag: Patient safety

On Strike

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Red Square and Suzzallo Library, University of Washington. Photo credit: Josephine Ensign/2015.

What would happen if you didn’t show up to work, if you walked out of work, if you went on strike? Would anyone notice? Would anyone suffer? Besides earning a (hopefully ‘living wage’) paycheck and (hopefully) decent benefits including heath insurance, how essential is the work we do? And just how expendable are we?

These questions have been on my mind over the past several weeks as a labor dispute rumbles along at the University of Washington in Seattle where I teach. Our faculty members are not unionized, but our teaching assistants are part of the labor union UAW Local 4121. They just voted (90% in favor) to strike if their union representatives can’t negotiate a new work contract with the university by April 30th. Among the union’s terms is one calling on the university to adhere to the City of Seattle’s new minimum wage ordinance that went into effect at the beginning of this month. They are also asking for better health insurance benefits. Their most recent (and first ever) strike was for fifteen days at the end of the academic year in June 2001. Fortunately, I was not teaching at the time, but I understand that the strike created a problem for final exams and grades. (See Columns: University of Washington Alumni Magazine article “Briefing: First Ever TA Strike Hits UW Campus.”)

By now we are all aware of the escalating cost of a college education. An increasing body of research indicates that the largest contributors to this tuition increase are the expansion of the number of university administrators and their inflated (six and seven digit) salaries. The increase in tuition certainly is not going to increased salaries/benefits for most faculty members or to graduate student employees (nor to improved teaching facilities/see paragraph below). An April 5, 2015 NYT op-ed article by Paul F. Campos, “The Real Reason College Tuition Costs So Much,” is refreshingly direct and clear on these issues.

There are approximately 4,500 teaching and research assistant graduate students who work for the University of Washington. My son is one of them, as is my current and best ever teaching assistant. She helps me keep track of and grade all the weekly writing assignments for the close to 150 senior nursing students in a writing-intensive health policy course. She also helps me do battle with the antiquated A-V classroom equipment. Just last week she helped me avoid being electrocuted by a malevolent, malfunctioning microphone that they had jury-rigged to a large boombox on the podium (because the A-V equipment had completely died). I am (still) here to attest to the fact that teaching assistants are indispensable.

And while union membership has been declining in the U.S. over the past several decades, it has been increasing for healthcare workers, and especially for nurses employed by hospitals. That hospitals, including the supposedly not-for-profit hospitals, are big businesses that run like factories, is a well-established fact. Healthcare reform efforts have placed increasing financial pressures on hospital administrators who typically turn these into ‘lean work’ initiatives for the hospital employees below them. ‘Lean work’ probably has some fancy management-speak definition, but it really means that those lower in the food-chain (such as nurses) run their butts off trying to do more work with far less resources.

As Alana Semuels writes in The Atlantic (“The Little Union that Could” November 3, 2014), the small but growing union National Nurses United (NNU) has been especially effective at battling the Goliaths of healthcare power and at winning many of these battles. NNU has pioneered the use of one-day strikes to pressure hospital administrators to provide nurses with the resources they need, such as safe nurse-to-patient ratios and adequate Ebola safety equipment. When Arnold Schwarzenegger was Governor of California and tried to block a state law that would provide safe nurse staffing levels, the nurses of NNU helped to block the Terminator’s block: California remains the only state to mandate safe nurse (RN)-to-patient ratios in hospitals. Yes! Power to the people/nurses!

Here’s some interesting food for thought: When physicians strike, patient mortality goes down; when nurses strike, patient mortality goes up. A physician colleague of mine always tells my students this when he gives a guest lecture in my health policy course. It always grabs students’ attention and it’s not just a random, sensationalized statement. It is backed by a growing number of studies from the U.S. and from other countries (see below). In healthcare, the work of nurses matters. In higher education, the work of graduate student teaching assistants matters.

****** References:

“Evidence of the Effects of Nurses’ Strikes”  by Jonathan Gruber and Samuel A. Kleiner, National Bureau of Economic Research, March 2010.

“Doctors’ Strikes and Mortality: A Review” by Solveig Cunningham, Kristina Mitechell, KM Venkat Narayan, Salim Yusuf. Social Science and Medicine. 2008. 67:1784-1788.

Seattle Times article “Grad students employed by UW vote to strike if contract talks fail” by Katherine Long, April 22, 2015.)

“UW regents flee as student activists speak up” by Katherine Long, April 8, 2015, Seattle Times.

Forgotten Nurses

This week I read the poignant and humorous essay “Lullaby” by Rebecca Ashcroft about her work as a night shift nurse at a hospital (In: The Healing Art of Writing. U CA Press, 2011). She makes the case for why night duty nursing works best for her while she is raising two children. She gets to go to soccer practices and piano recitals. But she doesn’t gloss over the downsides of night nursing—the falling asleep at inconvenient times and in inconvenient places, the mood swings/crabbiness of sleep deprivation, etc.

Night shift nurses are sometimes referred to as the forgotten nurses. Most patients in hospitals (if they are lucky) sleep through most of the night and never really remember the nurses who check on them in the wee hours of the morning. Nursing leadership and the rest of hospital administration acknowledges their essential function, but rarely actually see them. Working night shift is often considered a career stall if not an outright career killer, because of the invisibility to daytime administration. It’s also sometimes looked down upon as the ‘easy shift’ since not as much is going on during the night—no tests or surgeries being scheduled for patients. The hard part of night shift nursing is the pesky sleep issue for nurses, so it still comes with a pay differential.

Early in my career when I worked as a hospital nurse on a spinal/brain injury rehab unit, I chose to work evening shift. This was when they still had three 8-hr hospital nursing shifts instead of the more common 12-hour shifts they have now. I liked evening shift because it wasn’t as hectic as daytime shift with its PT/OT/procedures, so I got to spend more time one-on-one with my patients, as well as with their families. When I worked in a nursing home as a nurses’ aid I sometimes was asked to work an evening and a night shift back-to-back when they were understaffed. I remember stumbling home after those double shifts as if I were drunk. Indeed, sleep deprivation can be as bad as alcohol intoxication for basic brain functioning. Not safe for driving home after work and not safe for patient care duties.

Research shows that night shift nurses have higher “sleep debt,” worse circadian rhythm disorders (think chronic jet lag), higher risk of obesity (poor eating options at night plus hormonal/metabolic imbalances from night duty), and higher rates of certain types of cancers (especially colon cancer). Lack of adequate sleep and working too many consecutive hours is linked to higher risk of serious patient adverse events. This is why there have been significant changes by accrediting bodies limiting hours of medical residents (to 80 hours/week). This is similar to aviation rules mandating maximum number of hours that pilots and flight attendants can work. The aviation rules are better enforced since it is a federal mandate through FAA. Limits to medical resident hours are voluntary and rely on self-report.

Ann Rogers, who is Associate Professor at the University of Pennsylvania School of Nursing is an expert on the issue of night shift nursing, health and patient safety. In Patient Safety and Quality: An Evidence-based Handbook for Nurses (AHRQ, 2008) she has a chapter entitled “The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety.” There’s a handy algorithm for nurses to use in assessing risk due to sleep deprivation/disruption. It starts with “Have you had at least 7 hours of sleep in the 24 hours prior to starting your shift? It includes “fatigue management” strategies, including naps and caffeine use. Seemingly not endorsed by Starbucks, she writes, “Caffeine should be used therapeutically. Caffeine should not be consumed on a regular basis or when alert.” (p 11)—then “Do not consume caffeine outside of work.” (p. 12) This does not seem to be very practical advice. The short naps strategy can work, but only if supported by colleagues and administration. Many nurses do not even get to take uninterrupted scheduled lunch breaks—which is when sanctioned naptimes could occur.

Hospitals provide 24/7 nursing care, so night shift nursing is an essential—if forgotten, overlooked, or undervalued—part of heath care. I raise a toast (of my double-tall vanilla soy latte) to all you dedicated if sleep-deprived night nurses out there!

Temporary Nurses and Patient Safety

1966 Nurses Strike - San Fransisco Where It Al...
Image by nursing pins via Flickr

California is the only state that mandates minimum nurse to patient hospital staffing ratios. So when hospital nurses go on strike in California, the hospitals postpone elective surgeries in order to reduce patient numbers, and hire temporary nurses to maintain the mandated nurse staffing levels. The recent patient death from a medication error by a temporary nurse at Alta Bates Summit Medical Center in Oakland during a nurses’ strike, has drawn attention to temporary nurses and patient safety.

Late last month more than 23,000 nurses at Sutter, Kaiser, and Children’s Hospital Oakland had a one-day planned strike protesting proposed cuts in employee benefits and patient services. Sutter hospitals locked out the nurses for four days after the strike, saying they had to sign five to eight day contracts with the firms who brought in the temporary nurses. During the lockout a temporary nurse reportedly administered a nutritional supplement through a central line (into the bloodstream) instead of through an abdominal feeding tube. Hospital spokespersons have called it a highly unusual medication error, but quickly added it didn’t have anything to do with the lockout or the use of temporary nurses. Nurses’ union officials have said the patient death wouldn’t have happened if they hadn’t been locked out after the strike. They have filed a complaint with the National Labor Relations Board over the lock out. And they have stated that it reveals that the use of temporary nurses endangers patient safety.

So what is the evidence in terms of temporary nurse staffing and patient safety and quality of care? An oft-cited study by Linda Aiken published in 2007 in the Journal of Nursing Administration, did not find that hospital patient safety was negatively affected by use of temporary nurses. However, her study used survey/self-reported data, and only included Pennsylvania hospitals. A recent large national study found that emergency department medication errors associated with temporary staff were more frequent and more likely to be life-threatening than those by permanent staff (Pham, et al, Journal of Healthcare Quality, July/August 2011). The authors point out that the use of temporary nurses (and other hospital staff) is on the rise due to work-force shortages and perceived cost savings to hospitals.

To Err is Human: Medical Errors and the Consequences for Nurses

The Neonatal Intensive Care Unit.
Image via Wikipedia

That medical care can be harmful to your health or even deadly, is not necessarily news to many people. The extent of it within the US health care system and the impact of it on health care providers are not well known. The IOM Report To Err Is Human: Building a Safer Health System (2000) highlighted serious patient safety issues in our health care system and outlines approaches to patient safety improvement. This report emphasized that the vast majority of adverse patient events were the direct result of bad systems and not of bad health care providers. “The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.” They pointed to the aviation industry as a model for safety design at the systems level. Root cause analysis was applied to understand and try to prevent adverse events. “Never events” were identified as sentinel patient safety events for monitoring purposes in hospitals (these include surgical removal of the wrong body part and inpatient suicides). National level patient safety monitoring databases were developed. Eleven years later where are we in terms of progress on patient safety?

In the April edition of the journal Health Affairs, indications are that we have not improved much and may actually have worsened. A study by Classen, et al reveals that serious preventable adverse events occur in one out of every three hospital admissions. Another study estimates a $17.1 billion annual cost of measurable medical errors in the US.  They point out that the risk of harmful errors in health care in the US is increasing due to the increasing complexity of care and of medical devices and medications. What to do about this? The Agency for Healthcare Research and Quality is putting an emphasis on educating patients on ways to advocate for their own patient safety (or parents of pediatric patients). But as Donald Berwick points out in the April 15th Health Affairs Health Policy Brief on improving quality and safety, “Commercial air travel didn’t get safer by exhorting pilots to please not crash. It got safer by designing planes and air travel systems that support pilots and others to succeed in a very, very complex environment. We can do that in healthcare, too.”

I have been thinking about the issue of patient safety and the consequences for nurses because of the recent news of the suicide of a respected local RN, Kimberly Hiatt. She died April 3rd at the age of 50. She had worked as a NICU nurse at Seattle Children’s Hospital for almost the past thirty years. I did not know her personally, but by all accounts she was a devoted and highly capable and compassionate nurse. In fact, Megan Moreno, a pediatrician who did her fellowship at Seattle Children’s Hospital and whose daughter Fiona died in the NICU of congenital health problems describes Kimberly Hiatt in an article published in the Archives of Pediatric and Adolescent Medicine (January 2006). She writes, “Our favorite nurse was assigned to us the next day, and she helped us through the difficult task of extubating Fiona.” At the end of the article she expresses particular gratitude to Kim Hiatt, RN, along with her neonatologist.

Kimberly Hiatt committed suicide because of a cascade of adverse events that happened to her in the aftermath of a medication error that resulted in an infant’s death in the NICU at Children’s. This happened in September, 2010 just months after a highly publicized death of a 15 year old autistic boy after routine dental surgery at Children’s, which resulted from an incorrect dose of a Fentanyl patch (a powerful narcotic) prescribed by the dentist. Children’s Hospital changed its policies on the prescribing of narcotics after this incident, but the dentist was not disciplined. Around the same time, an ER doctor at Children’s incorrectly administered a drug to a critically ill patient by IV instead of by an injection in the muscle, and the patient had to be transferred to another hospital because of the complications. The physician was not disciplined.

In contrast, Kimberly Hiatt was fired soon after the infant’s death. Also soon after the infant’s death, Children’s Hospital changed its policies to require stricter control and checks on the administration of the specific medication, calcium chloride, which is considered an especially dangerous drug  in medically fragile infants.  Dr. Hanson, the Medical Director of Children’s Hospital said that it was important that all staff feel safe to report mistakes. The Washington State Nursing Commission put restrictions on her nursing license with a four-year probationary period; with these restrictions no one would hire her to work as a nurse. According to a Seattle Times article (4-20-11), many hundreds of former patients and their family members, as well as nursing colleagues attended her funeral. In the Seattle Times Editorial and Opinion pages today, F. Norman Hamilton, a retired anesthesiologist writes, “The fact that the hospital changed its policies after the death implies that they realized that its policies were inadequate. Despite this, the hospital decided to fire the nurse for an arithmetic error. (…) If we fire every person in medicine who makes an error, we will soon have no providers. (…) It is my belief that if the nurse had been dealt with appropriately—with compassion and insight—that she, today, would be a valuable and happy nurse.”

So I am left with many questions. Why was the nurse treated so differently from the   dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes—and usually due to unsafe staffing levels they have no control over—what do I teach my students to do? If the suicide of a hospital patient is considered a sentinel “never event,” shouldn’t the suicide of a nurse such as Kimberly Hiatt due to systems errors be considered a “never event?”