Why Do We Continue to Harm Patients?

SafetyNurse1968, ADN, BSN, MSN, PhD

What ONE THING would you do today (the sky is the limit here folks) to reduce harm to patients?

WAKING UP TO A NIGHTMARE

Imagine waking up from surgery in a hospital bed - you can't move, you literally cannot speak, lift a finger or communicate that you are awake in any way. Over the next few days, as you drift in and out of consciousness, you realize from the conversations going on around you that you have been in the ICU for three weeks. Over the next weeks of recovery, you come to realize that during surgery - a standard hysterectomy for a diagnosis of uterine cancer - your bowel was nicked. Your post-operative pain was ignored for almost 36 hours, and you ended up septic and in the ICU. This story is from Anatomy of Medical Errors: The Patient in Room 2 by Donna Helen Crisp1 - she was a professor of nursing at the UNC school of nursing and this happened to her.

In another book about medical mistakes, Wall of Silence2, Rosemary Gibson and Janardan Prasad Singh, share horrifying stories of medical error, including a widower whose wife died of cancer that was spotted three years before her death but never treated, a woman who died from sepsis after hemorrhoid surgery, a man who was supposed to have his left lung operated on, but had the right one operated on instead. On the ProPublica Patient Safety Facebook page3 you can read daily accounts of the suffering of individuals from medical error. These are stories from people who have been harmed in our care - in the care of a system that was supposed to at least try to heal them.

PATIENT SAFETY

I am obsessed with patient safety and the prevention of harm from medical error. Wherever I go, I talk to people about my obsession, and people open up to me. At the National Patient Safety Conference in 2017, I bonded with a sales-rep over the death of his father, who had gone into the hospital a healthy 82-year-old needing a routine procedure. He died there 6 months later of pneumonia. At a local safety conference, I listened to a young nurse tell a roomful of her peers about an insulin error she was involved in. She bravely recounted her story so that we could learn from it.

A report in 2000 by the Institute of Medicine4 estimated that in healthcare, about 40,000 people die each year from medical error (this number is a gross underestimate - current estimates put deaths from a medical error at more like 400,000 people5). The IOM used an analogy that has haunted me since I read it. It is as if a jumbo jet, fully loaded with passengers, crashes each WEEK and there are NO SURVIVORS. If that happened, don't you think someone would get upset? And yet in healthcare, because these are silent, individual deaths, often covered up by shame, secrecy, and even illegal activities - nothing is done. There is no huge media circus each time one person dies as a result of a medical error, but the cumulative effect is catastrophic.

IMPACT

And what about the impact -- the harm done to patients and families, the needless millions of dollars spent by individuals, healthcare organizations and taxpayers, the emotional suffering of everyone involved - patient, family member, nurse, doctor...the entire healthcare team becomes the victim when an error occurs? The culture of blame and shame so rampant in health care adds to the impact of error by making it extremely difficult for those involved in errors to find support. Victims of medical error often suffer alone, in silence, isolated by an event over which they had no control.

LET'S TALK

Let's open a dialogue. I want your stories, but more importantly, I want your solutions. As nurses, we are in a prime position to impact patient safety because WE know the patient best- that's our job. We are taught in nursing school to "be careful" and to follow the five (or six, or nine, or 12) rights to prevent error, but despite this - nurses continue to make mistakes. In fact, it is unlikely that a nurse will complete their career without making an error6. Does that mean nurses who make errors are bad nurses? Does this mean they just weren't careful enough? Perhaps something else is going on? The modern patient safety movement suggests that instead of focusing on individual responsibility, we focus on SYSTEMS causes for errors - things we can change about our environment, working situation and organization to reduce harm from error.

What works for you? Please share some success stories with me as well as mistakes. I am going to be writing a lot about this topic in the months to come. I will be sharing interviews with nurses involved in error, guidelines for how to "mistake proof" your practice, and information you can USE. Keep your eyes open for safety checklists you can share with friends, family, and patients to prevent harm.

ONE THING

What ONE THING would you do today (the sky is the limit here folks) to reduce harm to patients? To get some ideas and solutions go to my favorite source - the National Patient Safety Foundation/Institute for Healthcare Improvement (NPSF/IHI). If you can't find any ideas there, try the Agency for Healthcare Research and Quality (AHRQ).

REFERENCES

1. Anatomy of Medical Errors

2. Wall of Silence

3. ProPublica Patient Safety Site - Facebook

4. Kohn, L., Corrigan, J., & Donaldson, M. (2000). (Editors). To err is human: Building a safer health system. Washington DC: National Academy Press.

5. Classen, D., Resar, R., Griffin, F. (2011). Global "trigger tool" shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30, 581-9. doi: 10.1377/hlthaff.2011.0190.

6. Anderson, D. J., & Webster, C. S. (2001). A systems approach to the reduction of medication error on the hospital ward. Journal of Advanced Nursing, 35(1), 34-41.

7. NPSF/IHI

8. AHRQ

smartassmommy · Feb 21, 2018

Ratios! Overloaded nurses are more likely to make mistakes.

Daisy Joyce · Feb 22, 2018

Better staffing

BeccaznRN, RN · Feb 22, 2018

Top-notch incentives and benefits for senior, experienced nurses to stay at the bedside. We need their knowledge and expertise to help keep our patients safe.

SafetyNurse1968, ADN, BSN, MSN, PhD · Feb 22, 2018

I have two comments already about staffing - and you are SO RIGHT - the next question is - so what are we going to do about it? Would you be willing to share strategies you are using to advocate for better staffing ratios?

From the ANA:

"States with Staffing Laws

14 states currently addressed nurse staffing in hospitals in law / regulations: CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA.

7 states require hospitals to have staffing committees responsible for plans (nurse-driven ratios) and staffing policy â€“ CT, IL, NV, OH, OR, TX, WA.

CA is the only state that stipulates in law and regulations a required minimum nurse to patient ratios to be maintained at all times by unit. MA passed a law specific to ICU requiring a 1:1 or 1:2 nurse to patient ratio depending on stability of the patient.

MN requires a CNO or designee develop a core staffing plan with input from others. The requirements are similar to Joint Commission standards.

5 states require some form of disclosure and / or public reporting â€“ IL, NJ, NY, RI, VT"

Please consider joining the ANA (if you haven't already) and support PAC funding to lobby our legislators to pass The Registered Nurse Staffing Act.

Would love to hear more about your efforts in your state.

SafetyNurse1968, ADN, BSN, MSN, PhD · Feb 22, 2018

Top-notch incentives and benefits for senior, experienced nurses to stay at the bedside. We need their knowledge and expertise to help keep our patients safe.

I agree BeccaznRN - and I have another question - how can we go about making this happen? It seems like nurses know what needs to happen for safer care, yet "nothing ever changes" - please share strategies you have used to get these sorts of incentives implemented.

JKL33 · Feb 22, 2018

Kristi,

This is not directed at you personally, but at the whole "safety" bubble: Some of this is getting exceedingly disingenuous at this point.

I understand why frontline staff must be involved in solutions, and we want to be, but you know as well as I do that the first 30 "holes in the swiss cheese" are things that bedside RNs can't fix, and what's worse, we are very likely to be vilified for caring too much about them or calling any attention whatsoever to them. So then, all of this becomes a bit of a game where we're playing by ourselves.

These nearly 20-yr-old reports and terrible (actually awful) analogies about how many people we're killing have ceased to be useful in this conversation except as attempts to make those with the least power in our organizations suffer with ongoing guilt - while those who shouldn't be able to sleep at night continue to shirk responsibility.

"We" are not sociopaths out killing jet planes full of people.

If you want to help patients (and nurses), the only way is to get real. Nurses and Safety teams have been coming up with mostly asinine (and some good) suggestions the whole time our profession has been being taken over by business people and their hired cheerleaders, who make up whatever facts are needed to suit their cause. And as far as I can see, the "cause" is to appear to be doing something about safety. It's very useful for the public to believe that uncaring, undereducated, poorly-prioritizing RNs and callous, money-hungry jerkwad physicians are the cause of safety issues. Well, we have made a ton of strides and now it is time for others to step up to the plate.

Sorry. I know your work is important but this conversation needs to change in a big way.

What am I going to do about it???? > Spread the word about this damaging, devaluing and demoralizing farce.

SafetyNurse1968, ADN, BSN, MSN, PhD · Feb 22, 2018

Kristi,
This is not directed at you personally, but at the whole "safety" bubble: Some of this is getting exceedingly disingenuous at this point.
I understand why frontline staff must be involved in solutions, and we want to be, but you know as well as I do that the first 30 "holes in the swiss cheese" are things that bedside RNs can't fix, and what's worse, we are very likely to be vilified for caring too much about them or calling any attention whatsoever to them. So then, all of this becomes a bit of a game where we're playing by ourselves.
These nearly 20-yr-old reports and terrible (actually awful) analogies about how many people we're killing have ceased to be useful in this conversation except as attempts to make those with the least power in our organizations suffer with ongoing guilt - while those who shouldn't be able to sleep at night continue to shirk responsibility.
"We" are not sociopaths out killing jet planes full of people.
If you want to help patients (and nurses), the only way is to get real. Nurses and Safety teams have been coming up with mostly asinine (and some good) suggestions the whole time our profession has been being taken over by business people and their hired cheerleaders, who make up whatever facts are needed to suit their cause. And as far as I can see, the "cause" is to appear to be doing something about safety. It's very useful for the public to believe that uncaring, undereducated, poorly-prioritizing RNs and callous, money-hungry jerkwad physicians are the cause of safety issues. Well, we have made a ton of strides and now it is time for others to step up to the plate.
Sorry. I know your work is important but this conversation needs to change in a big way.
What am I going to do about it???? > Spread the word about this damaging, devaluing and demoralizing farce.

I think what you are trying to say is - stay away from the histrionics - the alarming stories cause more harm than good. It also sounds like we have a difference of opinion as to how to go about improving the safety of our patients.

My goal is to incite action, and in that I believe we are unified. Thank you for spreading the word about empty promises and weak actions being taken by healthcare facilities. I will continue to spread the word about how nurses can empower themselves to make positive changes through political action and voting with our feet, while fully realizing these aren't options for all nurses, I hope to inspire some nurses to do more. Only 3% of us are active - I would argue that if nurses increase our voice (since we continue to be the most trusted providers in healthcare), we might perhaps cause some positive change.

Sincere thanks for your input and feedback.

CityofAngelsRN · Feb 22, 2018

I have worked at three hospitals, 2 being magnet hospitals using Epic and the new one that is still using paper charting and no barcode system for meds. This causes so many mistakes. I overheard a charge nurse say she almost makes a mistake once or twice a week. That is unacceptable. At this point, all hospitals need scanning systems.

SpankedInPittsburgh, DNP, RN · Feb 22, 2018

There's no magic to better staffing ratios. It's more money for nurses. Unfortunately every trend I see is the opposite. When hospitals became a business we nurses became an expense to be minimalized. How do we combat this? Join a strong union. Become politically active. Educate your neighbors.... It would take all the above but first nurses need to form a united front on these issues & I've seen no evidence of that at all

SafetyNurse1968, ADN, BSN, MSN, PhD · Feb 22, 2018

There's no magic to better staffing ratios. It's more money for nurses. Unfortunately every trend I see is the opposite. When hospitals became a business we nurses became an expense to be minimalized. How do we combat this? Join a strong union. Become politically active. Educate your neighbors.... It would take all the above but first nurses need to form a united front on these issues & I've seen no evidence of that at all

Now that's what I am talking about! If we joined together - just think what we could do? I appreciate the positivity of your statement - we CAN do this - we have to CHOOSE to do it.

SafetyNurse1968, ADN, BSN, MSN, PhD · Feb 22, 2018

I have worked at three hospitals, 2 being magnet hospitals using Epic and the new one that is still using paper charting and no barcode system for meds. This causes so many mistakes. I overheard a charge nurse say she almost makes a mistake once or twice a week. That is unacceptable. At this point, all hospitals need scanning systems.

I hear you, and yet I also find it interesting that depending on the study you read, CPOE or barcode admin can cause an increase in error. I think it has to be more than just tech - it has to be a change in culture. Healthcare has to stop blaming individuals and open up to the idea that we are absolutely going to make mistakes - there is no shame in making mistakes. Let's just get that out of the way, admit it, stop firing nurses for doing their jobs, and begin to value the folks who work at the bedside with better hours, higher pay and some respect.

Why Do We Continue to Harm Patients?

What ONE THING would you do today (the sky is the limit here folks) to reduce harm to patients?

Have you ever made an error that caused patient harm?

1. Have you ever made an error that caused patient harm?

WAKING UP TO A NIGHTMARE

PATIENT SAFETY

IMPACT

LET'S TALK

ONE THING

About SafetyNurse1968, ADN, BSN, MSN, PhD (Member)

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