Please be sure to read this most inspirational post about Charity Hospital’s 9 West medical first responder team, and their courage in caring for their patients and each other. The team was stranded for six days during Hurricane Katrina. Dr. Ruth Berggren tells her story to Dr. Pauline Chen for the New York Times Well Blog.
Insanity is doing the same thing over and over again, expecting different results.
The health care industry likes to compare itself to the airline industry on issues of reporting safety concerns and quality control. In a weird way, there is a parallel comparison between flight attendant Steven Slater’s dramatic exit from a jet last week and nursing. While the media and lawyers discuss Slater’s actions, I find myself wondering which daily, routine complaint about nursing is the one that could make me grab a couple of pudding cups out of the patient nutrition fridge and run screaming “I quit” through a fire exit during a hospital fire drill? Maybe I should have a few head shot photographs on hand for the media if it happens. You want a reality nurse show? I’m your girl.
A pilot told me the most common reason a flight is delayed for take off is because someone forgot to order ice for the beverage cart. It takes fifteen to twenty minutes to correct the oversight. The most common reason patient care is delayed in a clinical setting is a lack of physician orders.
Physician’s (or Nurse Practitioner’s) orders are the foundation of bedside nurse practice. Even with a patient sitting in front of you, demanding care, a nurse can do very little without a clearly written, dated, signed order with two patient identifiers (name and date of birth). These precise rules of communication are safeguards of patient safety. Enforcing them does not reflect obstinacy on the part of the nurse. Because of this, trauma centers and high acuity areas like intensive care have protocols and collaborative practice order sets so nurses can start treatment in the absence of a physician, should crisis occur.
The patient with an appointment at an infusion clinic is usually not in crisis. The most common reason their appointment is delayed is the lack of physician’s orders. Often, there is an order, but it has the wrong date. Or there isn’t a patient’s name on it. Or the dose, or licensed practitioner’s signature was omitted. Or the MD’s office receptionist, who isn’t licensed, signed it. The variables are endless. When I pick up a chart and find an incomplete order, I call the doctor’s office for a legal order so that the appointment doesn’t have to be rescheduled, but there’s usually a delay. Physicians are as busy as nurses. If they are on, they are with patients, either in the office or at the hospital. Or they’re in their car somewhere between the office and the hospital (the era of them being on the golf course is long gone since before I was a nurse).
Lots of things have changed during my twenty+ years of nursing, but what constitutes a valid doctor’s order has not. We’re all human, and busy, and things get missed. Some doctors have software on their office computer that prompts them to write a complete order, and provides an electronic signature. This way, their office staff can pull it up and fax it to the clinic without interrupting the physician when they’re called for unsent or misplaced orders. Many hospitals are converting to physician computer order entry to prevent treatment delays and errors. However, most urban physicians admit patients to multiple hospitals, and this solution requires them to learn multiple computer programs. Understandably, many are resistant to do so.
And this is the quandary: Hospitals and infusion clinics depend on physicians to admit patients to them. Keeping them happy is a part of customer service. So, hospitals and infusion clinics are reluctant to mandate physician computer order entry. However, this creates another customer service problem: the delay or rescheduling of a patient’s treatment, resulting in unhappy patients who may choose to go elsewhere for services.
Sometimes when I phone a physician for orders after the patient has arrived for their appointment, he or she will say, “My office faxed those orders three days ago. Why am I getting called on the day of the appointment to fix my orders?” That is a very good question, and it’s the one that makes me feel like I’m taking crazy pills. How does a patient get an appointment scheduled if they don’t have valid orders, or any orders at all?
Someone forgot to order ice for the beverage cart. Someone forgot to look over the orders when they came through the fax machine.
People are human and mistakes happen. When the same problem occurs frequently, over and over again, something is wrong. There are many factors in health care beyond the control of physicians, nurses, and management, so that when there are factors that can be controlled, we should do so.
Before someone grabs a couple of beers and slides down the emergency chute.
Fellow Portlander, Registered Nurse, and blogger Peggy McDaniel posted this on my Facebook Wall yesterday:
Make a difference and help out Dr. Janie. Copy and paste this as your profile status. Help underprivileged kids get critical medical care by voting for Rose City Pediatrics Pepsi Refresh grant. Vote today and every day through the end of the May. http://www.refresheverything.com/healthcareforunderinsuredkids
Yesterday morning, I attended an awards breakfast at the hospital I work for, honoring 105 nurses with Certificates of Nursing Excellence. My colleagues were recognized for developing patient safety and education programs, precepting, and academic or certification achievements. I received recognition because the American Journal of Nursing published my painting Love You to Death on its October 2009 cover. I was scheduled to work during the breakfast, but two days earlier, our manager arranged patient scheduling so I could attend, without burdening my coworkers with extra work.
The usual hospital administrators, with the addition of a Chief Nursing Officer, presented the awards. This executive nurse sits on our hospital’s Board. To my knowledge, she is the first nurse to sit on the Board. She makes significant contributions to nursing management.
Recognition for hard work feels good.
There are more than 105 excellent nurses working at our hospital. Many simply did not fill out the form required to receive recognition. They choose to work hard without it. We are all wired a little differently, in that respect. I used to prefer staying under the radar too. But part of taking care of me is taking time to celebrate accomplishments, instead of keeping track of failures. What you focus on expands.
Happy Nurses Day.
I wish declaring war on Iraq had stirred the same amount of energy which Health Care Reform has. Each endeavor involves spending huge sums of money and pivots on lives in the balance.
The anger of those opposing Health Care Reform is vehement. Crowds shouting slurs at senators, threatening them with violence in voice messages for voting in favor of the bill, while prominent citizen and member of the opposition Sarah Palin tweets Don’t Retreat, instead RELOAD! to her followers demonstrates that no one is safe from bullying and workplace violence.
I would like Health Care Reform to go further, still, it’s a big step towards the betterment of the lives of our citizens. Its importance became real to me last week, just days after the bill’s passage, as I listened to young patients living with treatable, chronic illnesses tell me that they are enrolling in college, or taking the job offered to them, because they no longer have to plan their lives around qualifying for disability payments for their pre-existing conditions. Hearing young adult patients express how a future of independence has suddenly opened up for them, because Health Care Reform passed brought tears to my eyes. I wonder if those who oppose Health Care Reform are so blind that a tear could not escape from their eyes too, if they could see what nurses see.
On Tuesday, February 16, 2010, JParadisi RN’s Blog had the most site hits since its debut in January, 2009. The day is notable, because the blog’s post Whistle Blowers & Patient Advocates: When the Nurse Stands Alone was mentioned by Shawn Kennedy on the AJN blog, Off the Charts. I assumed the two events were connected. Imagine my surprise: they are not. The stats for JParadisi RN’s Blog show that the most popular post on February 16 was an older post: Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or His Patient. For the entire week that post and the posts with updates about Eric Cropp were the most viewed on my blog.
Eric Cropp served 6 months of imprisonment for involuntary manslaughter in the death of 2 year-old Emily Jerry. Emily Jerry died when she received a chemotherapy solution containing a lethal dose of sodium chloride mixed by a pharmacy technician at the hospital where Eric was the supervising pharmacist. The Ohio Board of Pharmacy stripped Eric of his license prior to his conviction. Now a convicted felon, he will never practice pharmacy again.
Why the renewed interest in the Eric Cropp case, during the immediate aftermath of the Anne Mitchell trial? Anne Mitchell, RN was publicly supported by the Texas Nurses Association and the American Nurses Association. The TNA donated funds for Mitchell’s legal defense, and the Texas Medical Board acknowledged Mitchell’s duty as a patient safety advocate. Mitchell was found not guilty. There were no fatalities in the Anne Mitchell case. The most obvious difference drawn from a comparison of the two trials is that a child’s death initiated the criminal charges against Eric Cropp. Perhaps this explains why pharmacist professional associations appear silent on the matter. Searching two prominent organizations websites with the keywords “Eric Cropp” I found only one article about the case on one site, and none on the other. Granted, defending a person accountable for the accidental death of a toddler creates an unpopular challenge in public relations.
Physicians are familiar with lawsuits involving the death of patients. It is rare for a doctor to go to prison or be stripped of his or her license in such a case. Eric Cropp was convicted of criminal charges in the absence of public support, except for Michael Cohen of ISMP. Whether this is right or wrong is a matter of opinion.
The pharmacy profession lost an opportunity to speak about patient safety systems, staffing issues, medication compounding practices, pharmacist to technician ratios, and other problems similar to those nurses have brought to public attention for years. In contrast, the TNA, and ANA used Anne Mitchell’s trial to educate the non-medical public about the patient safety advocate role of nurses. It is important to remember that the non-medical public is unfamiliar with common hospital practices. In my opinion, there is an expectation for professional organizations to educate the public on the scope of practice of its members. It is unfortunate that this opportunity was missed during the Eric Cropp trial.
Did a lack of support and public education lead to the setting of a disturbing precedent: the criminalization of medication errors? (Will the Criminalization of Medication Errors Make Patients Safer in Ohio?).
Eric Cropp was released from jail on February 15, 2010, and this explains the increased traffic to JParadisi RN’s Blog on February 16, in the aftermath of the Anne Mitchell case. It was only a coincidence. Whether or not pharmacists compare the two very different outcomes of these trials, I do not know.
I am married to a pharmacist. However, for most of my career, I was a pediatric intensive care nurse dedicated to saving the lives of children like Emily Jerry. I saw firsthand families devastated from losing a child under less unusual circumstances. The opinions expressed in this post do not diminish my sympathy or empathy for the family of Emily Jerry.
A colleague and I discussed the Winkler County Whistle Blowers case and our admiration for Registered Nurses Vicki Galle and Anne Mitchell. They brought the nurse’s role of patient safety advocate into the national spotlight.
My colleague is also a force to reckon with when it comes to patient advocacy. During our conversation she grew quiet and told me once, she had advocated for a patient without the support of her peers or administration.
The event occurred early in her nursing career, before she gained the skill and knowledge, which now empower her ability to act confidently as an advocate. In the end, she followed orders, even though they conflicted with her ethics. Decades later, she still regrets her choice.
I listened to her story, and tried to imagine her as a young nurse, uncertain and faced with a situation nursing school had not prepared her for. I imagined her alone and isolated, the only one in a nursing unit who felt, or more likely, spoke out loud the feeling that what was happening might not be best for the patient.
The Winkler County Whistle Blower case demonstrates that this kind of moral isolation still happens to nurses. However, it also demonstrates that nurses have developed resources for themselves and learned how to access them. These days, many hospitals have ethics committees and safety committees for reporting unsafe systems and behavior. Many hospitals have policies protecting nurses who refuse to administer treatments that conflict with their moral beliefs. Winkler County Memorial hospital fired Anne Mitchell and Vicki Galle when they used the hospital’s safety chain of command to protect patients, but the hospital and the doctor bringing charges against them found out this kind of punitive behavior is no longer tolerated by the court system or a majority of health care professionals. The Texas Nurses Association and the American Nurses Association said, “We are watching,” as did the Texas Medical Board. I’ve heard the conversations of doctors who ask why Dr. Arafile’s colleagues didn’t report his behavior. Why was the responsibility left to nurses? If any of these resources were available for my nurse colleague when she faced her dilemma decades ago, I would be surprised.
My heart breaks for that young nurse, facing an ethical dilemma alone and unsupported, with nowhere to turn. I told my colleague I hope she has forgiven that young, inexperienced, and frightened version of herself, with her older, more experienced self’s compassion. I suggested that what she learned from that episode long ago has forged her into the warrior nurse advocate she is today, benefiting hundreds of patients during her long career as their advocate.
The idea that the Health Care Reform bill is on life support is disappointing, but not surprising. It was admitted in a weakened state of health. It appears suspiciously a victim of domestic violence by special interest groups. The bruises on its body resemble the outline of handprints of the insurance companies it was created to protect our citizens from. Already, my patients are complaining of rising health insurance deductibles this year. It is estimated that 14 million people will still be uninsured if the Health Care Reform bill rallies and passes. It is a complex piece of legislation that confuses even those of us who strongly advocate for health care reform. I think that’s where the undecided get lost and fall to the wayside; afraid to support what they do not understand.
In my grief over Health Care reform, I console myself by remembering that at least it’s a step in the right direction. At least an estimated 34 million currently uninsured citizens will be insured, and people who are currently insured won’t lose their insurance if they change jobs or become ill. These are progressive and necessary improvements to the present situation. I tell myself that if we lose this moment in history, it won’t come again anytime soon. Something is better than nothing. Fight for the life of the Health Care Reform bill, don’t let it slip away.
But I know, even if successfully resuscitated, it will not be the strong, idealistic super hero it once was. It is anemic. The bill has been bled by special interests groups and insurance companies. It’s vital organs have been damaged by poor perfusion (lack of blood supply). It is now being threatened with further leeching in order to get even a shadow of its former self passed into legislation.
Health Care is a human rights issue. Human rights issues are intimately linked to economics. Historically, in most countries, including the United States, it is this link that causes resistance. It is the cause of resistance to Health Care Reform now. Until Health Care is recognized as a fundamental human right, and not a for- profit industry, our citizens will continue to suffer.
I have a special place in my heart for Dr. Susan Love. When I was diagnosed with breast cancer almost eleven years ago, her book, Dr. Susan Love’s Breast Book was my resource for navigating all the information and treatment options I was suddenly confronted with. As a pediatric intensive care nurse, I was almost as unfamiliar with my diagnosis as any non-medical woman might be. Dr. Love’s informative, and practical approach to breast cancer helped me gain a sense of control over what was happening to me.
Now Dr. Love is back, with a new book Live a Little! Breaking the Rules Won’t Break Your Health (Crown). The book is reviewed by Tara Parker-Pope in a post New Health Rule: Quit Worrying About Your Health on the New York Times Well Blog.
While it’s not the purpose of this blog to offer medical advice, I will admit that one of the lessons I learned from my cancer experience is that perfect health does not exist. I realized I did not fight so hard against cancer to spend the rest of my life following a strict life style and worrying about recurrence. I was living a pretty healthy lifestyle prior to my cancer diagnosis. I continue to do so. I know that living with healthy habits , while helpful, does not offer any guarantees. With so much data about what to eat and drink to prevent cancer and heart disease (don’t drink wine, drink wine ), recommendations for scheduling enough sleep and exercise into a day, Dr. Love’s sensible approach is a welcome relief.
“But what about the Pirate’s Code?” Elizabeth, (Keira Knightley), asks Captain Barbossa, played by actor Geoffrey Rush, as he reneges on a bargain she’d negotiated with him, in a scene from the movie The Pirates of the Caribbean: The Curse of the Black Pearl. “Well,” Barbossa replies, ”…the code is more what you’d call ‘guidelines’ than actual rules,” and he sails off, keeping her captive.
I’m reminded of this scene while reading the post by Anahad O’Connor, What’s Your Temperature? Rethinking 98.6 in the New York Time’s Well Blog (December 28, 2009). Many commenters posted annoyance with nurses and doctors who seem to ignore them when they explain that their temperature is usually lower than 98.6°Farenheit ( which is 37° Celsius, used in most other countries than the United States ). As a Registered Nurse, almost every patient I see in a shift tells me their temperature normally runs below 98.6. I know. So does mine. Most of my patients run a little below 98.6, in the 97′s. However, 98.6°F has become a cherished rule in our society, by which patients decide if they are sick. If they are higher than 98.6°F, they reason they are sick.
98.6°F is an average body temperature. This means there is a range of some degrees below and above that are considered a normal body temperature. It’s a guideline, and only one factor in the assessment of whether or not a patient has an infection (viral or bacterial). Many adult patients present with an infection without reaching a temperature of the textbook rule 101°F. There are a few more guidelines I want to consider: What is the patient’s blood pressure, and how does it compare to the patient’s blood pressures in the past? When I suspect infection, I’m often more concerned with a drop in the patient’s blood pressure, than an increase. Is the pulse (heart rate) higher or lower than usual? Is the patient complaining of pain or achy? Is she dizzy? Is there a rash or swelling anywhere? Finally, what is my overall impression of the patient? Does she look sick to me? If vital signs are borderline normal, but my gut tells me the patient is ill, I’ll call her doctor to discuss the findings. I’ll actually tell the physician, “The numbers are normal, but she is symptomatic (has symptoms) and she looks sick to me.” You’d be surprised how many doctors order blood cultures, a chemistry panel, CBC, a urine analysis, and prophylactic antibiotics based on a phone call like that from a nurse, especially in oncology.
My point is to illustrate why, when you tell your doctor or nurse that 98.6°F is high for you, it seems we aren’t listening to you. What we are doing is looking and listening to you, to decide what the best plan of care might for you. 98.6°F is only a guideline, not a code.
Disclaimer: It is not the intent of this blog to dispense medical advice. If you have concerns about fever, infection or other personal health issues, please consult a licensed medical practitioner.