Nurse Safety

Gabriel Blaj - Fotolia.com

While this Op-Ed that appeared in the New York Times is written from the perspective of a doctor, a lot of it applies to various healthcare providers who have more information than the patient does.

The doctor, Danielle Ofri, writes of a patient she calls Julia, with whom she had a lot in common; both were about the same age, both were mothers with two young children. They were even about the same height and the same build.

But only one was facing a death sentence. Julia had a serious heart condition that meant she would die, fairly soon.

Ofri writes of the recent findings that physicians are not always open or honest with patients within this context. An article in the journal Health Affairs found that more than one in 10 physicians had told a patient something that was not true within the past year, and almost one in five had failed to reveal a medical error. More than half had put a more positive spin on a prognosis than was warranted.

Ofri expresses some surprise that the numbers are so low, but also questions how nefarious the reasons behind those numbers actually are. While she knows that she should have gone ahead and told everything to her patient, her own emotions got in the way.

When Julia walked out of our hospital without full knowledge of her prognosis, I had been derelict in my duty as her physician. I was fully aware that my job was to have “open and honest” communication with her, in a “patient centered” manner. But I couldn’t. I couldn’t bring myself to tell this young mother that she was going to die.

It could be that I over-identified with my patient, or that I let my emotions get the better of me, or that I was an out-and-out wimp. No doubt all played some role, but I wasn’t the only doctor who struggled with the truth. Everyone responsible for her care — intern, resident, medical attending, cardiology fellow, cardiology attending — independently fell short of the Charter on Medical Professionalism. Young, old, male, female, touchy-feely, egotistical, blustery alike — not one of us could say those words to her face.

When it comes to medical error, doctors have an even harder time coming out with the truth. There is, of course, the well-founded fear of malpractice litigation. Momentum is growing for legislation to protect doctors who acknowledge error and apologize. But beyond the fear of malpractice, there is the larger issue of shame at failing at your job, of letting a patient down, that makes you want to hide. It took me two decades to speak publicly about my first major medical error.

I was one week out of my internship at the time, and my patient was admitted nearly comatose with what is called diabetic ketoacidosis, from a severe lack of insulin. After we’d brought him back from the brink and could finally turn off the intravenous short-acting insulin drip, I committed the cardinal error of neglecting to inject him with long-acting insulin. He promptly barreled downhill again. A senior resident rescued him before he had a cardiac arrest, then screamed her lungs out at me in front of the entire emergency room staff.

I never mustered the courage to tell the patient what happened. So great was my shame that it was 20 years before I could begin the “open and honest” communication that the situation deserved.

Are doctors simply cowards? Do our own existential fears paralyze us? Human beings, by nature, prefer to avoid horrible truths, and denial may be our most powerful survival skill. Doctors are no more nor less immune to this, and to the basic human drives of empathy and pity, than anyone else.

By now, even the most hard-core, old-school doctors recognize that emotions are present in medicine at every level, but the consideration of them rarely makes it into medical school curriculums, let alone professional charters. Typically, feelings are lumped into the catch-all of stress or fatigue, with the unspoken assumption that with enough gumption these irritants can be corralled.

The emotional layers in medicine, however, are far more pervasive. Emotions have been described by the neuroscientist Antonio Damasio as the “continuous musical line of our minds, the unstoppable humming …” This basso continuo thrums along, modulating doctors’ actions and perceptions, while we make a steady stream of conscious medical decisions that have direct consequences for our patients. Emotions can overshadow clinical algorithms, quality control measures, even medical experience. We may never fully master them, but we must at least be conscious of them and of how they can sometimes dominate the symphony of our actions.

Julia did eventually get the truth of her diagnosis, at her first post-discharge clinic visit. The actual moment was — as expected — horrible. It took several tries for us to get the words on the table. Voices choked, eyes brimmed — and that was just the doctors. Julia was more stoic. She nodded slowly, very slowly, as she pieced it all together. The quiet that followed felt like a licking of the wounds for all parties. All wasn’t sunny and optimistic, but there was a sense of reality, and now the planning could begin.

Why did it take us so long to tell her? It might have been that we doctors first had to come to terms with the diagnosis ourselves — however selfish that might sound. Perhaps, unconsciously, we were trying to give Julia breathing room. But all this may have been mere justification to make us feel better. The fact is that we didn’t tell her the whole truth, up front, as we should have.

I’d like to say that I’d handle the situation better now, with another decade of clinical experience under my belt, but I’m not sure. Today, at least, when my medical team faces the prospect of giving bad news or admitting a medical error, I try to help my students and interns pay attention to the basso continuo running underneath. I try to point out when our emotions might be impeding us, and when, as sometimes happens, they might be assisting us in caring for our patients. Doctors can’t — and shouldn’t — eradicate the emotions that grease the wheels of patient care. But being alert to them can help us minimize where we fall short, and maximize where we succeed.

Image courtesy of Daniel Paquet via Flickr

A consensus statement and call to action to help healthcare personnel avoid needlesticks has been issued by the American Nurses Association and the International Healthcare Worker Safety Center at the University of Virginia.

The statement is meant to be “a roadmap for future progress,” according to this article on Nurse.com.

The consensus statement and call to action highlights five especially important areas to address. They are improving sharps safety in surgical settings; understanding and reducing exposure risks in nonhospital settings; involving frontline healthcare workers in the selection of safety devices; addressing gaps in safety devices and encouraging innovative design and technology; and enhancing worker education and training.

The president of ANA, Karen Daley, RN, PhD, MPH, FAAN, contracted HIV and hepatitisC from a needle while tending to a patient in the Emergency Department in 1998. Ever since then she has been a staunch advocate for needlestick safety.

“Needlestick injuries are preventable and cannot be tolerated as a cost of doing business,” Daley said in an ANA news release. “Healthcare organizations are charged with ensuring safety and preventing harm — to patients, employees and the public. Unfortunately, needlesticks still occur, whether from lack of education and training, complacency or frugality.”

The federal Needlestick Safety and Prevention Act was passed in 2000, a boost in the effort to reduce the risk of healthcare worker exposure to blood-borne pathogens. But Daley said the law does not by itself ensure worker safety.

“Nurses need to hold employers accountable for following the law and refuse to accept anything less,” she said. “Progress has been made, but the law provides only a framework. It is up to people to create the culture of safety necessary to minimize incidents.”

Healthcare workers in nonhospital settings account for about 65% of the U.S. healthcare workforce, a proportion that will continue to grow over the next decade. Although safety-engineered devices are in widespread use in most hospitals and clinical laboratories, market data show a lag in their use in other settings.

The U.S. Centers for Disease Control and Prevention, the National Institute for Occupational Safety and Health and other government agencies, as well as nongovernmental agencies and professional organizations, should support epidemiological research that evaluates risks to workers in a wide range of nonhospital settings, according to the statement. And professional organizations representing nonhospital care settings should make sharps safety a priority and ensure availability of appropriate devices and educational and training materials specifically for workers in these settings.

“While we celebrate the progress we have made, we must acknowledge the gaps that exist,” Jagger said in the news release. “We must redouble our efforts to ensure that all healthcare workers, regardless of the setting in which they practice or the procedures they perform, are offered the same standard of protection from sharps injuries and exposures to blood-borne pathogens.”

Minnesota State Capitol courtesy of TBoard via Flickr

Nurses in Minnesota are calling for new legislation that would set a limit on how many patients may be assigned to hospital nurses.

A one-day strike by the Minnesota Nurses Association in 2010 was focused on the issue of safe staffing, and union leaders are now accusing hospital officials of breaking promises made after that strike to address staffing questions. The nurses feel that inadequate staffing is endangering their patients, and have collected nearly a thousand reports in just the last half of 2011 to support this claim.

The president of the nurses association, Linda Hamilton, said in this article in the Minneapolis Star-Tribune, “”We’ve been left with no choice but to take our concerns to the state Legislature.”

The new legislation, called the 2012 Staffing for Patient Safety Act, would set a maximum number of patients for each nurse, depending on the level of care required. For example: no more than three patients per nurse in emergency departments, or four patients per nurse in medical and surgical units.

Union officials were joined by two legislative supporters, Sen. Jeff Hayden, DFL-Minneapolis, and Rep. Larry Howes, R-Walker. Hayden said the Legislature generally “doesn’t like to get in the middle” of such disputes, but that in this case, “it’s a necessary evil.”

Two years ago, the union tried unsuccessfully to get hospitals to set specific nursing ratios as part of a new contract, a goal the national union has pressed in other states as well.

Ratios termed unworkable

Hospital officials argued that staffing ratios are expensive and unworkable.

The standoff led to a one-day walkout by some 12,000 Minnesota nurses in June 2010. They eventually reached an agreement that called for the two sides to work together on staffing concerns.

But the problem is “worse than ever,” according to a statement released by the union. Hamilton said the hospitals have been “stonewalling” attempts to address safety concerns, and that “we need legislation like this to hold hospital administrators accountable and keep our patients safe.”

The union cited several examples of staffing reports filed by nurses in 2011, although it declined to give details because of privacy laws. One said that a patient had fallen, “with significant injuries,” because the nurses had too many sick patients at the time. Another said a nurse was unable to properly comfort the parents of a dying baby because she had to care for another infant at the time. The union said the incidents are typically reported to hospital supervisors at the time.

Massa, though, said hospitals need flexibility to respond to changing demands, not inflexible ratios. “We both want to see the best quality care for our patients,” he said. “We just don’t think that this is the right way to approach it.”