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Never Events and Preventable Errors

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I am a health care writer with extensive professional experience as a clinical nurse in critical care/adult health nursing, as a hospital administrator responsible for patient safety, performance improvement, patient care and also as an undergraduate nursing educator in academic settings.

I am a health care writer with extensive professional experience as a clinical nurse in critical care/adult health nursing, as a hospital administrator responsible for patient safety, performance improvement, patient care and also as an undergraduate nursing educator in academic settings. As an integral part of doing my job in more than one hospital, I experienced retaliation and retribution for simply being an effective patient advocate and nurse advocate.  My credentials and background are listed more in depth on the "About" page of my dormant blog called Universal Health.  The url for visitors is http://universalhealth.wordpress.com. I also maintain a current blog called Home of the Brave at url http://revolutionredux.wordpress.com.

I have written about catastrophic and lethal preventable errors in healthcare on both blogs.  Tragically, I had written about the deaths of three infants from the identical heparin administration error that occurred at The Methodist Hospitals in Indianapolis a year earlier than the Quaids' experience.

Catastrophic errors are sometimes referred to as "never events," meaning that they exist only because of multiple systemic failures and that they have catastrophic consequences.  Never events are preventable, and they provide fodder for system analysis and process improvement.

Being a patient is unlike any other "consumer" experience.  Patients, for the most part, are not in that role by choice.  They are under health stressors, usually are experiencing symptoms which are in some way disturbing or are disruptive.  They are often not able to perform all of the activities they choose to do routinely, and moreover, they may be forced out of desired social role function, such as performing parental duties, attending work, maintaining optimal function and productivity, engaging in desirable activities, engaging socially, etc.  They may be fearful of losing a body part, of suffering a disfigurement, of confronting the end of life, of dealing with an overwhelming illness, injury or condition, or of not being able to find adequate relief from distress.

So it's with all of these variables in play that patients seek the care of physicians and nurses.  Arguably, patients are not in ideal positions to be able to leisurely and voluntarily "shop" for their health care and providers and make choices based entirely on preference and other free market factors.

As patients in healthcare institutions, patients are most often very vulnerable to perceived and actual powerlessness and loss of control.  Patients are dependent to varying degrees for their very lives on physicians for their degree of accuracy and timeliness of diagnosis and plans of treatment and care, and on nurses for the receipt and coordination of all healthcare services.  Professional nurses (meaning nurses licensed in their state of practice as registered nurses) are the providers charged with maintaining patient safety throughout all aspects and locations of patient care.

In the OR, the circulating nurse is charged with maintaining the sterile field and sterile technique of everyone in the room with the patient.  Although all members of the OR team are expected to self report breaks in technique or to point out breaks, it is the circulator who is ultimately responsible for everyone and everything at all times.  The circulator maintains the meta safety of the patient.

In all settings, the professional nurse is responsible for recognizing and processing physician prescriptions (orders) for patients.  They have the legal and ethical responsibility to question orders which are not congruent with recognized standards of practice and care, the legal responsibility to refuse to carry out those suspect orders until their rationale has been adequately supported with evidence, and they have the ultimate responsibility for assuring that all patients under their care receive the right medications and the right care at the right time, in the right dose, by the right route, and in the right setting.

All technical and unskilled staff who perform nursing functions are accountable to a registered nurse (or to a physician in a physician directed setting, such as a medical office).  Professional nurses may have a direct patient care assignment of four patients, yet have nursing extender workers caring for many more, thus making their patient responsibility ratio enormous and well past what any individual person could reasonable oversee to assure patient safety.

Add to that a chaotic and disruptive work environment which leads to almost every nurse being continually interrupted throughout all apsects of work - from assessing patients, to processing medical orders, to teaching patients, to preparing medications, to administering medications, and you can see where the potential for making erros escalates.

Nurses almost all work as direct employees of healthcare institutions.  Nursing "leaders" are no such thing.  They are nurses hired by institutions to provide direction and management of nurses, nursing services and patient care resources.  Indeed, these nurses affiliate with and are loyal to hospital administrators and boards of directors.  Their national organization, the American Association of Nurse Executives (AONE) isn't affiliated with the national organization for nursing, the American Nurses Association.  Rather, the AONE is a subsidiary of the for profit American Hospital Association, which represents corporate interets and assuredly not the interests of patients and nurses.

Finally, the Institute of Medicine commissioned a seminal study in 1999:  to Err is Human:  Building a Safer Health System.  The url is http://www.iom.edu/CMS/8089.aspx .  Linda Aiken, a researcher at the U. Penn, studied mortality and morbidity rates of post operative surgical patients and found that morbidity and mortality rates significantly increase (patient outcomes are worse) when patients do not receive adequate amounts of nursing care in a timely manner from nurses who are minimally educated at the baccalaureate level or above. Yet only one thrid of nurses in the US have this level of education at a minimum.  The Institute for Healthcare Improvement (http://ihi.org) has waged a large scale national campaign called Saving 100K Lives which aimed evidence based best practice intervention bundles and online education and support for healthcare institutions. I've been part of planning and instituting several programs at two different institutions which demonstrated better desired patient outcomes (a decrease to zero in the number of pneumonias in patients using ventilators, lowered infection rates for patients receiving central venous access catheters and in lower numbers of patients who suffer a cardia arrest with the introduction of rapid response teams).

There are lots of straightforward system improvements which are pragmatic, reduce overal costs and improve patient safety andoutcomes.  But they are all predicated on having enough professional nurses to take care of all patients in a timely manner without undue interruption and disruption, the ability of nurses and physicians to control their own professional practice, and the ability of nurses to self-govern.

I was last employed just over two years ago at a very prominent academic teaching center as a throughput officer.  Horrible name, but the mission was to reduce or eliminate patient delays from all sources of admission.  The vision was to provide all patients the right service at the right time by the right provider in the right setting.  If that rings a bell, it's because it's congorunet with the principles of safe medication administration: right drug, right dose, right route, right time, right patient.

In the course of orienting myself to the stakeholders: physicians across all services which admit to the hospital, patients, nurses, healthcare workers, support services, etc., I uncovered egregious administrative acts and practices which were illegal, unethical and which ultimately adversely affected patients and patient safety.  Two weeks after expressing frustration with a human resource manager, I was wrongfully terminated, blacklisted, ostracized and today am still unemployed, homeless, destitute and haven't been able to impact the practices which I uncovered in the first place.

In my view, much of what impacts patient safety includes corporate will, free market unregulated profit and the desire of employing patient care institutions to capture market share over providing essential patient services.  In my experience, patients get the best care when they are VIPs, have the most highly reimbursed diagnoses, and have the demographics congruent with organization donors.

I would love to work again - but never as a hospital or patient care institution employee.  I would love to help to move professional nursing along a path of greater professional autonomy, of practice via independent nurse-governed professional practice groups, and in establishing the baccalaureate degree as the sole minimal educational crednetial for all nurses.

For as nursing goes, so goes the health of the nation.

Professional nursing, empowered patients.  Good health.

Newsflash

Quaid Discusses Medical Mistakes

Quaid spoke at the HIMSS09 this year. Read this article of the discussion and speech that Dennis gave as a keynote speaker.

See the full article here...

 

Important Messsage

Our experience has shown that medication errors can and do occur at hospitals throughout the country, even the best ones like Cedars-Sinai. В We now want to work with hospitals to help support their efforts to eliminate medication errors.

 
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