Behind Closed Doors Case #21: “He Said… She Said”

Summary: NY: missing signature on discharge summary: does this mean no instructions were given?

Information: DeLorenzo v. St.Clare’s Hospital of Schenectady, 2010-00433 (1/21/2010) –NY

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

     A glance into the ER waiting room reinforces your hunch that this storm has not yet subsided. There are no places to sit, patients lie on stretchers in the hallway, and there are more people signing in at the triage desk. Your hospital is situated just a couple miles up the road from the professional car racing facility and each year NASCAR related events seem to bring with them a nonstop flood of patients, rivaling those commonly seen during the holiday season. You sigh in exasperation, realizing that its only day two of the racing festivities and several more of these busy shifts are still on the horizon. At this moment you are waiting for two of your patients to look over their discharge instructions and prescriptions, sign their papers, and get dressed so that you can send them on their way and alert your charge nurse that the rooms are available. Making your way back into each room you find the the patients are seated and waiting for the “OK” to leave the ER. You bid each one well, advising them to drive safe, and collect your copy of the discharge instructions before signaling to the housekeeper that the room is ready to be turned over. On the way back to your seat at the nurse’s station you toss the discharge instructions into the Unit Secretary’s basket for processing, and search for your coffee mug. It’s way past time for a refill, and there are still six hours left to the night……

The Real Thing

     Jane DeLorenzo presented to New York’s St. Clare’s Hospital on October 14, 2004 to be treated for dog bites to her wrist and thigh. After being evaluated and having her wounds attended to, she was discharged from the Emergency Room with aftercare instructions. Jane presented once more for treatment the following day, concerned about worsening pain and red streaks that had appeared at the area of her wounds to the wrist, extending up the arm. An abscess was discovered on one of the wounds so Jane was admitted to the hospital for further treatment to remove it. She would later file a lawsuit against the hospital for what she described as poor medical treatment and faulty discharge instructions provided to her by the Emergency Room Nurse—during the discovery phase of the proceedings it was noted that Jane had not signed the discharge instructions given to her by the ER nurse which raised the question of whether she had received them at all.

Questions for Consideration

1. What are some actions the nurse could have taken to prove discharge instructions had indeed been provided?
2. How would you have documented the discharge encounter with this patient? Why?
3. Discuss some objectives and elements of nursing documentation. Provide your rationale.
4. What are some discharge teaching guidelines for nurses? Provide your rationale.

Discussion

     There are two main reasons we nurses chart what we do about patients—to communicate with members of the healthcare team and to protect ourselves from as much liability as possible while in the process of caregiving. This article is for you newly minted nurses out there who may still be under the impression that “you’re covered” under the wing of whatever corporate entity that you are working for. If a patient and/or family brings suit against a hospital (and thus everyone involved with the care of a patient) don’t expect for your defense to be a priority or for the hospital to be concerned with protecting you, your license, or your future. Priority one is to purchase nurse liability insurance (and do it now) before swiping in for your next shift. Priority two is remaining vigilant—with every patient, every shift– about what you are documenting, why you are documenting, and how you are documenting it. Doing it defensively could make or break not just a case—but your career:  ”Careful and complete documentation of nurses’ progress notes is a principal method of reducing the risk of liability in nursing malpractice lawsuits. They may sustain or preclude a suit for negligence from the outset. They may support or undermine the nurse-defendant before a jury in the event of a trial. In a negligence suit, nursing documentation will be as critical a factor as the nursing care itself. A nurse’s notes should provide answers to questions at issue in a lawsuit. They should not prompt more questions or raise additional issues.” (Sharpe, 1999) 

      Now you ask, “What makes up defensive nursing documentation?” Simple! Recall the nursing process—it’s the easiest way to remember how to cover yourself. Documentation should include your assessment, identification of patient needs, nursing interventions (in this case teaching methods and materials), and the patient’s response to interventions. Got an opinion about the patient’s overall presentation? PLEASE Leave it out—there’s no room for your subjective impressions of a patient or their situation. Keep it clean and objective. I know the Emergency Room is an exceedingly busy place to try and be effective as a nurse, but it goes without saying that slowing your roll and paying attention to little details like ensuring a patient actually signs the discharge paperwork is a vital part of the process and a big part of reducing liability to you and your institution. The old adage still holds just as true in the courtroom as it does in our practice environments: “If it wasn’t charted it wasn’t done.” Attorneys have a hell of a time trying to defend your course of action if there is no proof the actions really took place: “The defendant’s attorney will endeavor to show that, although there may be an apparent omission, the action in question was the nurse’s usual practice, which routinely need not be documented. Nurses cannot possibly function as court reporters or stenographers, transcribing the minute details of every event or conversation. However, if a nurse defendant’s notes do not corroborate his or her testimony, the nurse defendant will be challenged to persuade the jury to accept as credible his or her version of the events surrounding the alleged negligence. Regardless of he sworn testimony, the written entries in the medical record will serve as the definitive statement of what actually transpired.”  (Sharpe, 1999)

 

When preparing to discharge a patient, ensuring that you have documented your method of teaching, teaching content, as well as the patient’s return demonstration or verbalization of understanding confirms that the patient actually engaged in a conversation with you, had the opportunity to ask questions and voice concerns, and was satisfied with the information they received. Ask the patient if they are satisfied with their teaching session or the materials they received—if the answer is yes, you can add in a simple phrase stating: “patient verbalizes satisfaction.” Incidentally, satisfaction with the discharge process is a large predictor of whether or not patients will be readmitted to the hospital within 30 days with preventable complications. (ie: Coumadin toxicity in patients new to the therapy) A large quantitative study published in the American Journal of Managed Care reports that:“A substantial proportion of Medicare beneficiaries experience an unplanned hospital readmission within 30 days of discharge. Hospital readmission rates are an important measure of the quality and costs of healthcare. Recent estimates suggest that almost one-fifth of Medicare beneficiaries discharged from a hospital are readmitted within 30 days, resulting in an estimated annual cost of unplanned readmissions of $17.4 billion.^1,2 Although factors outside of the hospital contribute to unplanned readmissions,^3,4 the fact that one-quarter of readmissions occur within 30 days of discharge suggests that there is room for improvement in the quality of inpatient care and discharge planning.” (Boulding, 2011) So there’s a little inspiration for you outcomes driven nurses. Need a little more incentive? Here’s the take home message: Neglecting to effectively document any part of patient care is considered an act of omission that is just as detrimental to your professional well-being as failing to obtain the patient’s signature on any document that involves their care. After all, you know what they say… “The patient is always right.”

Works Cited

Boulding, W. G. (2011, January 25). Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days. Retrieved May 19, 2013, from American Journal of Managed Care: http://www.ajmc.com/publications/issue/2011/2011-1-vol17-n1/ajmc_11jan_boulding_41to48/1

Sharpe, C. (1999). Nursing Malpractice: Liability and Risk Management. Westport, CT, United States: Auburn House. Retrieved May 19, 2013

Tammelleo, D. (2010, February 1). NY: missing signature on discharge summary: does this mean no instructions were given? Retrieved May 20, 2013, from The Free Library: http://www.thefreelibrary.com/NY: missing signature on discharge summary: does this mean no…-a0221907925

Behind Closed Doors #20: “It wasn’t me.”

Summary: Dr. blamed nurse for post-appendectomy death

Information: Cuppy v. Gray, 2008 AZAPP1 1 CA-CV 06-0632 (02/02/2008) P3.d –AZ

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

      It’s 1900 hours and as per usual it seems like every patient in the PACU and the ER that’s been scheduled to transfer to your floor earlier is arriving now during report. You are one of the lucky nurses that get not just one new patient during shift report, but two. Both are from the PACU and require continued frequent monitoring for at least six more hours. “Of course they do,” You think to yourself.  With no time for anything but a terse and irritated exchange with the PACU nurses who both verbalize their readiness to “get out of here for the day;” you ensure each of the patients is alert, oriented, and has stable vital signs before signing the transfer forms the nurses hand to you. You’re anxious to get on with shift report, quickly waving them off before returning to the nursing station to catch up. If there’s one thing you hate, its being the last nurse in report and the last nurse in line at the Pyxis station to pull the night meds. As you set down your Kardexes, the call lights begin chiming overhead…………..

           The Real Thing

     Richard Cuppy underwent an appendectomy at a Banner Healthcare facility in Mesa,  Arizona on September 23, 2002, during which he had experienced some intraoperative bleeding complications. Around 8:40PM on September 24^th Mr. Cuppy’s condition had changed, arousing the concern of nursing staff. Despite this, no call was placed to the surgeon who had performed the surgery. In this unusual case, the family brought suit against the surgeon as the person responsible for the death of Mr. Cuppy. The surgeon, however, countered—alleging that the failure of the nurse to call him at “8:40 PM” when suspicions first surfaced that Mr. Cuppy wasn’t doing well was the cause of the patient’s death. He testified that had there been a call placed at the earliest suspicion of Mr. Cuppy’s change in condition a workup to rule out hemorrhage would have been initiated by him, which could have included blood work, fresh frozen plasma, and the cancelling of scheduled postoperative Lovenox (blood thinning) injections. There was a lack of evidence for the jury to establish that the failure of nursing staff to contact the surgeon at 8:40PM on the night of the 24^th was the direct cause of death. Nor did the jury deem that there was enough evidence to establish that the surgeon’s proposed interventions would have saved Mr. Cuppy’s life. An expert nurse witness did testify that the failure of Mr. Cuppy’s nurse to call “any physician or provider” fell below the standard of nursing care. “[T]he standard of care required that Nurse P contact the hospitalist at 8:40. Nurse P fell below the standard of care in failing to contact – to contact a hospitalist to inform them of these significant changes in Richard’s condition.” Likewise, although Nurse Ciribassi testified repeatedly that the standard of care would have required Nurse P to call “a physician,” she did not testify that Nurse P should have at any point notified Dr. G. Indeed, the only reference in her deposition testimony that was read to the jury that mentioned contacting a surgeon was the following: 13 Q: If that is the only conclusion [Nurse P] could come to is the patient was bleeding internally, even you would agree she was required by the standard of care to call the hospital[ist] or surgeon? A: If at that time she was caring for the patient . . . if she came to that conclusion, I would have expected her to call the hospital[ist] or the surgeon.” (Cuppy v. Gray, 2008)

During this rather messy case, the question of whom or what was the direct cause of Mr. Cuppy’s death was tossed back and forth like one of those big beach volleyballs we see at summertime concerts. The smallest of details were honed in on and up for argument. The family continued to allege that though they did not disagree the nurse’s lack of action fell below the standard of nursing care, they still believed that the lack of action and a series of “missteps” by the surgeon were the cause of their loved one’s death. It was eventually agreed upon that the failure of nursing staff to contact providers was a contributing factor that placed him at risk:  “Banner Health and its nursing staff provided inadequate, inappropriate, and substandard treatment to Richard Cuppy thus falling below the standard of medical care resulting in Mr. Cuppy’s ultimate untimely death. * * * Plaintiff asserts that Banner Health and its nursing staff and their various employees and agents treated Richard Cuppy in a negligent manner such that this negligence proximately caused actual and irreversible harm to Richard Cuppy resulting in his untimely death. * * * Ultimately Banner Health and its nursing staff[’s] negligent acts and omissions substantially increased the risk of harm to Richard Cuppy resulting in his death.” (Cuppy v. Gray, 2008)

Questions for Consideration

• Take some time to review your own state’s Nurse Practice Act. Pretend you are the nurse in question. What area(s) of the NPA were violated by failing to call a provider?

1. Review the Code of Ethics for Nurses. What, if any, provisions of the code were violated by failing to attend to the condition of Mr. Cuppy?
2. Can ‘omissions’ in the care of patients still get nurses into trouble? Why?
3. Discuss the differences between “negligent acts” and “omissions” in care.
4. How would reviewing the patient’s intraoperative note have helped the nurse to anticipate potential problems with this patient? What steps could she have taken to reduce Mr. Cuppy’s risk?

 Discussion

      Making time to review your patient’s medical records can be the single most valuable step you take when they are assigned to your care. The very first thing you should do after receiving report from the ER, the OR, or a nurse from another unit– is to go into investigative mode and find out what information exists about your new patient. Look at their initial HPI or their Emergency Room admission note. These two documents are a great start, and usually hold a goldmine of information about the patient. (I always go back later and look at the rest of the chart to find other details about the patient not given to me in report) Take notes and identify some potential needs the patient might have. While doing this, critically think about any risks that could place the patient in danger of sentinel events. Begin mentally constructing a care plan. Most importantly—Always ask yourself—what can I prevent and how?

      In this particular case I think reviewing Mr. Cuppy’s Intraoperative note or scanning through his lab trends might have revealed some key information, prompting the nurse to call the physician and inquire about whether the Lovenox was something the doctor still wished to have as part of the medication list. Perhaps there was a gap in the hand-off between the PACU and the floor nurse that allowed the detail of intraoperative bleeding to somehow slip through the cracks, leaving the floor nurse out of the loop. Maybe there was some kind of omission in Mr. Cuppy’s care. Unfortunately, communication breakdown is again one of the variables in this case, and study after study has verified the lethal consequences to our patients: “1. More than four out of five nurses have concerns about dangerous shortcuts, incompetence, or disrespect. 2. More than half say shortcuts have led to near misses or harm. 3. More than a third say incompetence has led to near misses or harm.” 4. More than half say disrespect has prevented them from getting others to listen to or respect their professional opinion.” In general, the results from The Silent Treatment 2010 study are in line with the Silence Kills 2005 data. But there are a few differences that need to be explained. More of the nurses in the 2010 study have concerns about dangerous shortcuts, incompetence, and disrespect; more have seen patients harmed; and more speak up about their concerns. The authors of the 2010 study believe these differences likely stem primarily from the differences in the two samples.The nurses in the 2010 study were more likely to come from settings where the job demands and patient acuity are higher: 87 percent work in an operating room, recovery room, ICU, cardiology unit, emergency department, or progressive care unit.”(Maxfield, 2011)

     Obviously we don’t have access to the medical record so that we can engage in the “armchair quarterbacking” us nurses are all so good at within the SoMe nursing sphere.  We could conjure up theories,  speculate about all the what ifs, take sides, and assign blame– but I like to look for solutions and offer up things I have done in my own career to not just protect my patient but to “CYA.” This time around I have identified my own personal practices of “anticipation and investigation” – as the two things I believe every nurse must do in order to reduce overall risk to our patients…and to our licenses. Once you accept a patient assignment, it’s show time and all eyes look to you—Never ever assume you have been given the whole picture in report.  

  

Works Cited

Cuppy v. Gray, 1 CA-CV 06-0632 (Stae of Arizona Court of Appeals Feburary 14, 2008). Retrieved May 18, 2013

Maxfield, D. G. (2011). The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives. VitalSmarts. Retrieved May 18, 2013, from http://www.aacn.org/WD/hwe/docs/the-silent-treatment.pdf

Tammelleo, A. (2008, April 1). Dr. blamed nurse for post appendectomy death. Retrieved May 18, 2013, from The Free Library: http://www.thefreelibrary.com/Dr. blamed nurse for post-appendectomy death.-a0178713108

Behind Closed Doors #19 Ready for Discharge? Not so fast….

Information: Carrano v. Yale-New Haven, 112 Conn. App. 767 (2/24/ 2009)–CT

Summary: Pt. discharged: dies next morning  from  fluid  filled lungs

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

      Mrs. Rodriguez, a widowed 68 year old mother to five, has been a long term care patient on your nursing unit for the better part of a month. For continuity purposes, you have been one of her primary nurses. Originally admitted for a simple urinary tract infection, she deteriorated to a septic state requiring a stint in the Intensive Care Unit. While there, she developed C-diff and some skin ulcerations on the sacral portion of her back. After a prolonged course of TPN to help boost her nutritional status and muscle building capabilities Mrs. Rodriguez was able to participate in an aggressive physical therapy regime where she eventually regained her strength. To her family’s delight, and to the nursing staff’s relief (the call light to her room will need to be serviced now), she is scheduled to be sent home to the care of one of her daughters tomorrow.

     It’s your second day of three and you feel a sense of accomplishment that you’re the nurse that gets to close out this case and see Mrs. Rodriguez on the way out to a healthier start than when she came in.  As you’re preparing her educational materials to begin some of the teaching that has to be done you hear a familiar hacking cough coming from Mrs. Rodriguez’s room. A CHF cough is different from other coughs so you get up to go investigate. She holds up a cup of ice chips one of her family members retrieved for her from the galley and laughs, explaining that it went down the wrong way. She is on a fluid restriction—so you remind the family (for the thousandth time) to keep track of how many ice cups they are giving their mother (on the dry erase board you’ve set up) so as not to exacerbate her well established Congestive Heart Failure. They reassure you they are on top of it. To be on the safe side you take a look at her I & O trends for the past 48 hours—she seems to be more on the plus side. Concerned, you report it to the PA on call for the primary service and continue to monitor her fluid intake closely for the remainder of the shift.

The morning of Mrs. Rodriguez’s discharge arrives and as you enter the unit the excitement is palpable– her whole family has shown up with a new scooter for her and breakfast for the nursing staff. Everywhere you turn people are posing for pictures with nurses, with Mrs. Rodriguez, with the medical staff, the housekeepers, and whoever else they recognize. Through the excited buzz in the nursing station and in her room you notice Mrs. Rodriguez’s face looks puffier today and she seems a little more short of breath. As you are mentally taking note of your concerns one of the primary doctors places a hand on your shoulder and proclaims Mrs. Rodriguez a “free bird as of right now!” He smiles proudly, handing you the discharge instructions, medication list, and prescriptions before helping himself to a doughnut handed to him by the patient herself. At the same time–her daughter, ecstatic, is asking whether you can take the IV out so that she can get her mother dressed to go home….

Before you can say another word, or voice your concerns, the medical team leaves the unit in one big swoosh of white coats to finish their morning rounds…..

    The Real Thing

     In February of 1992, Mr. Phillip Carrano sought treatment for a necrotic finger at Connecticut’s Bridgeport Hospital. Due to complications he began experiencing related to his Chron’s disease; Mr. Carrano was sent to Yale-New Haven Hospital on March 11^th for more specialized care. He was treated there for about a week when, on March 20^th, he underwent a colonoscopy to help providers decide whether or not surgery was needed to manage the Chron’s disease. Around the time of the colonoscopy Mr. Carrano began experiencing excessive swelling in his arms and legs. Despite this, he still was discharged on March 21^st.  The next morning Mr. Carrano died from an overload of fluid in his lungs.

Questions for Consideration

1. What role, if any, could nursing have played in the course of events?

2. What are possible causes for Mr. Carrano’s swelling being missed?

3. Could the nurses involved be held liable for negligence in the death of Mr. Carrano? Why?

4. In your opinion, was beneficence lacking here? If so how and by whom?

Discussion

     You’d think that excessive swelling in a patient’s extremities would be a pretty difficult thing to miss. Unfortunately, it can happen easier than one might imagine. I can think of three different ways for it to occur: 1.) Lack of bedside reporting 2.) Longer length of stay 3.) Computer charting.  In most facilities it is standard practice for nurses to perform and document at least one full physical assessment on their patients during a shift—more than that, depending on the condition and/or needs of the patient. But what an assessment “is” or “isn’t” depends on the nurses involved in the care of the patient and how willing one is to pull back the bed sheets, take off the TED hose, or go exploring underneath a patient’s gown to assess lungs sounds, chest tubes, or EKG leads. Defined as “communicating about the patient condition, nursing assessment, and required interventions at the point of patient care”(Evans, 2012)—The Bedside Report would have been a good save for not just the nurses involved with Mr. Carrano’s case—but quite possibly for the patient himself.

In matters pertaining to safe handoffs, The Joint Commission’s interest has been piqued for quite some time: “Motivated by sentinel events that identified handoffs between personnel as a pervasive problem, The Joint Commission originally established improved “effectiveness of communication among caregivers” as a National Patient Safety Goal in 2006. This goal requires institutions to develop a standardized approach to ‘handoff’ communication, including the opportunity for staff to ask and respond to questions” Additionally, National Patient Safety Goal 13.01.01 was added to ‘encourage patients to be actively involved in their own care as a patient safety strategy.”(Evans, 2012)  Now, whether or not patients are actually allowed to participate in their care to the fullest extent, or whether nurses are allowed to empower them to do so is a whole other novel in and of itself.  Mr. Carrano’s length of stay at Yale New Haven amounted to 10 days, which was more than enough time for nursing staff to get used to what his “reported usual assessment” was. Nurses– you know what that sounds like in report: “No changes today,” “he looks the same,” “nothing new to report.” As the length of stay increases it becomes easier to “stop looking” past the cognitive state of a patient, their vital signs, their IV site, or the meal trays and “happy clicking” on all those boxes in the computer charting software marked “Within Normal Limits.”

This case illustrates the importance of a thoughtful and thorough handoff process that includes both nurses laying hands on the patient to observe, compare and contrast assessment findings at the time care is turned over to the next shift. A form of routine interdisciplinary collaboration—like routine nurse/physician rounding on a shift by shift basis could have also proved useful in rescuing Mr. Carrano while he was still being hospitalized. It’s reasonable to assume that poor communication had a large part to play in the course of events. An AORN article highlights the correlation between communication problems and sentinel events:  “Communication failures were found to be the root cause of failure in almost 70% of all sentinel events reported to the Joint Commission. (4) There are various reasons for these communication failures. Clinicians may not possess effective written or verbal skills, or they may lack formal training in effective hand offs. Also, the hand-off process has not been standardized, creating the risk that clinicians will provide inconsistent levels and quality of information. The quality and safety of the hand-off process has been shown to be variable, unstructured, and error-prone.”  (Clancy, 2008)

Long term patients—we all have them—and performing what you perceive to be “the same assessment over and over again” probably seems tedious and time consuming. Add it up though—on any given day– one day shift nurse can decide to glance in a room and decide Mr. H looks the same as he has the past week, and that same evening a night shift nurse could decide to do the same. Mr. H. has now gone 24 hours without an actual physical assessment, though one for each shift is being documented in the computer as being “within normal limits.” One could also approach this scenario from the perspective of nurse advocacy. These days patients are processed at lightning speed– as one is being discharged there are usually two more people who require that bed for treatment and your charge nurse is likely the “oh so friendly” helicopter hovering over you to “wrap things up—yesterday.” If you feel something isn’t quite right with your patient and they are slated for discharge in the next few hours (or the next 15 minutes) it’s never too late to say something—it’s your duty.  

Patient care errors continue to kill thousands of people each year, and healthcare consumers are all too wise to that– often recruiting family members or trusted friends to remain with them in the hospital to ensure their best interests are served. This case, and others just like it, demonstrates why they should. I know that nurses have been crowned with the proverbial tiara –year after year— and named the “most trusted professionals” out there. But in this day and age–with workplace conditions as they are, high attrition rates, and increasing numbers of burned out professionals early into their careers– I’d heartily refute that commendation by stating that no one should be trusted above anyone else in the healthcare industry. All the more reason for you readers to carve out an extra ten minutes or so and take those extra steps I talked about in the beginning—lift up the sheets (and change them while you’re at it), take off the TED Hose, put the EKG leads on the right way, moreover– help the patient into a new gown so you can see what’s underneath there and assess them better. These aren’t just the tasks a patient care assistant does and there is some real incentive to you doing them yourself ….it may be you who prevents another tragedy from taking place.   

Resources

Burns, K. (2011, July-August). Nurse-physician rounds: a collaborative approach to improving communication, efficiencies, and perception of care. MedSurg Nursing, 20(4), 194-200. Retrieved May 15, 2013

Clancy, C. (2008, July). Improving the safety and quality of care transitions. AORN Journal, 88(1), 111-113. Retrieved May 15, 2013

Evans, D. G. (2012, September-October). Bedside Shift to Shift Nursing Report: Implementtion and Outcomes. MedSurg Nursin, 21(5), 281-292. Retrieved May 15, 2013

Tamelleo, D. (2009, April 1). Pt. discharged: dies next morning from fluid filled lungs. Retrieved May 15, 2013, from The Free Library: http://www.thefreelibrary.com/Pt. discharged: dies next morning from fluid filled lungs.-a0200251345

Behind Closed Doors Case #18 “Drama Queen”

Information: Harrington v. Regina Medical Center, 2004 WL 1728021 N.W.2d—MN

Summary: MN: ‘melodramatic … female’ misdiagnosed: patient ‘codes’ & dies from myocarditis awarded over $500,000

 Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

It’s New Year’s Eve and you’ve got some big plans for the evening. Tonight your guy is finally going to propose (you overheard him talking to his brother a week ago) and you have been counting down the days and hours to this day. Unfortunately there are still two hours left to go at the clinic and you’re the lucky nurse who gets to close it all down for the year before getting your party on tonight. As you hurriedly make your way through the pile of call backs and prescription refills the docs have given you to tie up, the phones continue to ring. You’re irritated and anxious, wondering why these people didn’t think to call at the beginning of the day versus now.

One of the last calls you take prior to forwarding the phones to the after-hours service is from one of the more frequently seen patients in the office—Mrs. Arias. She is a middle aged woman well known to the staff for her “histrionics” and long lists of maladies, earning her a spot on the short list of patients your coworkers prefer not to get trapped alone with in a room, much less in a telephone conversation if it can be avoided. You have her on speaker phone so that you can try and get some filing done while she drones on about various symptoms she is experiencing that seem to match the ones she has called about on at least 20 other occasions. “Hello? Are you there?” Her voice has a Jersey accent to it that seems to get a bit pitchy when she is irritated. Rolling your eyes and making a face at the phone you tersely reassure her that you are still there while reaching for her chart. After flipping it open, you note that she was in the ER within the past couple of days and diagnosed with her usual “Prinzmetal’s Angina & Acute Panic Attack.” Today she is throwing in “a little nausea” and a “general feeling of fatigue” into the mix. “Not today” you think to yourself, “there’s no time for this today.”

Clicking on one of the phone keys you take Mrs. Arias off of the speakerphone and advise her to take some of her scheduled medication and go lay down to relax for a bit. She wants to speak with her doctor but you know that all the docs are headed to some pharmaceutical gala at an upscale resort with their wives and none of them would be pleased at this interruption. You decide to be frank so as to cut this phone conversation short: “Look Mrs. Arias, its New Year’s Eve. All the doctors are at an event for the night and there is no one here in the office but me right now. Just take a couple of Advil for your headache or a Nitroglycerin for your chest pain and lay down. You’ll feel better after a while. The office is open again January 2^nd. If you want to call back then, we should be able to get you in to be seen.” After bidding Mrs. Arias a Happy New Year, you quickly hang up the phone, forward the calls to the after-hours service, and breathe a sigh of relief. Thirty minutes later you click off all the lights and bounce out the door, smiling at the thought of returning to work in the New Year engaged.

 The Real Thing

      Patsy Myers was diagnosed with a viral syndrome on December 23, 1999 when she sought care from Minnesota’s Regina Medical Center. She had fallen ill for about a week with symptoms that included a cough, fever, and a sore neck. While in the Emergency Room, Patsy received a workup that consisted of a chest x ray, blood work, spinal tap, and a physical exam. Her discharge instructions included “rest, increase consumption of fluids, Tylenol as needed for pain, Robitussin CF for cough, and seek medical care if not better in three to four days.” (Free Library, 2004)  She was encouraged to seek further care if her symptoms worsened. On the afternoon of December 24, 1999 Patsy contacted her primary care physician’s office because she was feeling worse and was having a difficult time standing. She was told by an unnamed office staffer that because she “only had the flu” and since it was late in the afternoon on Christmas Eve she should continue with the Tylenol and fluids. The next evening Patsy returned to the Emergency Room for new onset shortness of breath and nausea—in addition to the other symptoms she had been experiencing. The Emergency Room physician reviewed Patsy’s chart and discovered she had already been put through a barrage of tests just two days earlier. His notes described Patsy as  a “melodramatic  white middle-aged female” who was not in “ respiratory distress.” (Free Library, 2004) She was again discharged from the ER with instructions to drink more fluids, take over the counter Advil as needed, as well as Compazine and Percocet. Less than 24 hours later Patsy was again transported to the ER at Regina Medical Center in a shock like state. She coded and died shortly after her arrival from what was later determined to be acute myocarditis. …She was only 49 years old.

 Questions for Consideration

 Assuming it was a nurse who spoke with Patsy on Christmas Eve; did he/she go beyond scope of practice? If so, how?

1. Think of some occasions when you or coworkers have labeled patients. What are common reasons for this to occur?
2. In what ways does labeling patients detract from the quality of care all clients are entitled to? Does it violate basic human rights?
3. Identify some ways that labeling patients promotes gaps in a client’s hierarchy of needs? (Recall Maslow)
4. Would you agree that the less secure or satisfied a patient feels with their care the more likely they will be to escalate their concerns to the level of a lawsuit? (Recall Maslow’s Hierarchy of Needs, the concept of social justice within the hierarchy, and its application to nursing)

 Discussion

      I know  about irritating, repetitive, phone calls and call lights.  I used to work for an Internal Medicine physician way back in the day and virtually ran the office. He trained me to be his right hand girl and taught me all the ins and outs of being in the business. I had his schedule, his rituals, his likes and dislikes down to a science—toward the end of my first year in the clinic I could practically read his thoughts and finish his sentences. I had all the nuances down. I was proud of that—We were a well-oiled machine. When it’s that good I think there can be some danger in having the “perfect knowledge” about your work partner—the knowledge of what they will do or say in just about any given situation or how they will respond to specific patients. Within that comfort zone also lies the potential to make judgments which can ultimately harm a patient and put you in a courtroom and your license on the line for exceeding your scope of practice.

We’ve all seen and overheard patients being mislabeled. Those of you reading this and shaking your head “No” either haven’t been in the profession for more than five minutes or you’re just lying. There is the “emotional Fibromyalgia patient” that’s assigned a room way in the back of the nursing station so we don’t have to be bothered by them when we’re trying to chart, or the “PIA back pain patient” who’s “drug seeking tendencies” have them on the call light every hour– you get the idea. Ironically enough, nurses continue to demonstrate time and time again a surprising lack of knowledge when it comes to caring for patients with Fibromyalgia and chronic pain. Here’s a quick explanation of Fibromyalgia: “FM is a type of muscular rheumatism. Symptoms include a gradual onset of musculoskeletal pain often characterized as a deep and burning ache, variable in location, and radiating diffusely over many areas on the body. Associated symptoms include a triad of pain, sleep disturbance, and fatigue that exists in nearly all patients with FM. The temporal nature of these symptoms is variable, making it difficult to establish a universal pattern among patients. However, muscle stiffness and fatigue are reported to be most prominent in the early morning and in the early afternoon. Symptoms of FM have been reported to worsen with a range of factors that are largely cognitive, psychosocial, and behavioral in nature (Van Houdenhove & Luyten, 2008)” (Wierwille, 2012)

        It happens more than we care to admit, but we do label people. We do decide, via our own opinion, whether they *really have needs.* We nurses do subject people to inequities in care.I recently browsed through a discussion about Fibromyalgia at Allnurses.com that took place among a few Emergency Room Nurses where one nurse shares his/her perspective on Fibromyalgia patients:  “Everyone I know with fibromyalgia is A. A hypochondriac B. Clinically depressed or C. a drug seeker. I don’t believe in this diagnosis. Throwing oxycontin at aches and pains is like killing mosquitos with a sledgehammer. I am not against appropriate pain meds, especially in the terminal patient….dose ‘em up, I say, but not for people who are just not facing life square on…I hurt too after lifting obese geriatrics all night, but Im not going to whine for narcs!” (Allnurses.com, 2013) Beautiful, right? ER Physician notes aside, let’s assume Patsy was a chronic pain patient and that the staffer she spoke with was indeed a nurse who just wanted to close up the office and get home for the holidays. It isn’t an uncommon scenario to conjure up, really. That clinic staffer could have been you.

The take home message here is that there exists a real danger to both you and patients when acquiring the dirty little habit of mislabeling patients and placing them in categories that increase their chance of experiencing a sentinel event. Yet, we nurses make ourselves a part of that process by the way we document about our patients and what we say to providers that influences how a patient is treated: “Mislabeling a patient can lead to impaired and often adversarial relationships with the healthcare team and inappropriate treatment may be a consequence.” (Ashley, 2008) Mislabeling undermines the trust consumers have with nurses, isolates them from securing their basic human right to healthcare that is fair and equal, and it directly conflicts with the Code of Ethics for Nurses: “The American Nurse’s Association’s (2001) Code of Ethics for Nurses discusses the ethical and moral obligation to relieve patient pain. The Code of Ethics for Nurses has been produced to make clear the goals, values, and obligations of the nurse and is a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession. These obligations and duties are non-negotiable.” (Ashley, 2008) Sadly, many nurses continue to perceive that the use of ethics within nursing is optional.

Simply put, if you want to protect your license (and save a few lives while you’re at it) it’s best to ditch the biases you’ve been harboring about your local “frequent flyers,” exercise caution in what you say and how you chart, and remember your duty to care. Here is a not so subtle reminder that’s focus is on pain patients, yet its message is applicable to every patient population: “A nurse accepts the assignment of a patient in pain and that acceptance is the start of a relationship with that patient. To inadequately manage a patient’s pain (or other symptoms) breaches the nurse’s duty to that patient and puts the nurse’s licensure in jeopardy.”(Ashley, 2008)

Anyone out there feel like being subjected to a lawsuit alleging that pain and suffering were at the hands of a Registered Nurse who didn’t properly address pain and suffering?

I know I’m not jonesing….but then again, I’ve had just about enough legal proceedings in two years to last me two lifetimes.   

  

 Resources

The Free Library. (2004, August 1). Retrieved May 9, 2013, from MN: ‘melodramatic female’ misdiagnosed: patient ‘codes’: http://www.thefreelibrary.com/MN: ‘melodramatic … female’ misdiagnosed: patient ‘codes’ & dies…-a0121672732

Allnurses.com: Nursing Specialties: Emergency Nursing: Fibromyalgia. (n.d.). Retrieved May 9, 2013, from Fibromyalgia: http://allnurses.com/emergency-nursing/fibromyalgia-61003-page2.html

Al-Shaer, D. H. (2011, January-February). Nurses’ Knowledge and Attitudes Regarding Pain Assessment and Intervention. MedSurg Nursing, 20(1), 7-11. Retrieved May 9, 2012

Ashley, J. (2008). Pain Management: Nurses in Jeopardy. Oncology Nursing Forum, 35(5), 70-75. doi:10.1188/08.ONF.E70-E75

Wierwille, L. (2012). Fibromyalgia: Diagnosing and managing a complex syndrome. Journal of the American Academy of Nurse Practitioners, 24, 184-192. doi:10.1111/j.1745-7599.2011.00671.x

Behind Closed Doors #17: In the media–A Trail of Tears

Information: BRAILLARD v. MARICOPA COUNTY/No. 2 CA-CV 2009-0059

Summary: Diabetic mother denied nursing care dies of diabetic ketoacidosis

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

     In recent weeks I’ve learned a great deal about the challenges nurses face when trying to care for the inmates within the Maricopa County Sheriff’s Office Jail System. High staff turnover rates, inefficient and repetitive processes that leave gaping holes in the continuity of care, short staffing, and insanely toxic work environments are just a few of the problems that prevail within the ranks of nurses who work for the correctional health system in Arizona. That being said, nothing quite compares to the ongoing battles that face inmates housed at the jails. When it comes to trying to access timely quality healthcare services administered with compassion and competence– the foundations of professional, humane, holistic, safe and ethical nursing practice falls way below the bar set forth by both past and present leaders of our profession.

Deborah Braillard’s daughter

      I’ve been privy to so many conversations during which I’ve noted inmates being labeled as “no good,” or “undeserving” of timely, quality healthcare. The most common thing I have heard from *too many* nurses working in the correctional health system here in Arizona is “If these people didn’t do “X” or “Y” then they wouldn’t be here in the first place. Treating them like we treat patients in hospitals just makes it more comfortable for them to be here.” Sadly, it’s in the eyes of nurses that inmates become less than human and are judged for what they are brought to jail for, and are treated accordingly. Any sense of ethics is pretty much extinct.  There are two outcomes that are born from these beliefs — 1.) Patient care suffers and people get injured or die 2.) Our profession is negatively impacted by the views and actions of a few. Sadly enough, it’s usually the mentally ill prisoners who tend to fall through the cracks of compassion and advocacy:  “Mentally ill prisoners are much more likely to suffer physical abuse, earn disciplinary sanctions for breaking prison rules or failing to respond promptly to orders, and to accruefurther criminal punishment that extends the length of their confinement.19 Although some prison administrators do recognize mental illness as a mitigating factor as they assess infractions, those prisoners whose disabilities make it hard for them to comply with prison rules often end up with long periods of isolation. Isolation can deepen and exacerbate mental illness, and can promptacts of self-harm.” (Paz, 2007)

 In order to gain a broader view of how poor nursing practice is affecting the lives of inmates I will highlight the untimely and unnecessary death of a 46 year old Phoenix mother named Deborah Braillard who died at the Estrella Women’s Jail on January 23, 2005 from a diabetic coma after being refused medical and nursing care by the staff working at the jail. Even more shocking, are court affidavits and medical records that reveal evidence of attempts to falsify the documents. Ms. Braillard’s case illustrates a horrifying lack of advocacy, leadership, and caring on behalf of both the correction and nursing staff during the tragic three day period the valley mother languished at the Estrella jail. The following paragraphs illustrate the last days and moments of this Phoenix mother’s death.

Ms. Braillard was initially booked into the 4^th Avenue Intake jail on January 1, 2005 at 11 PM. On January 2^nd at 2:25 AM she was provided a medical exam/screening by a Registered Nurse that was recorded as having lasted only 59 seconds. Braillard’s previous medical records should have been accessed and reviewed upon admission into the 4^th Avenue jail but it’s here where the chain of events leading to her death takes a tragic turn when staff fail to initiate a search for previous medical records by communicating with that department to check if there were any available. Had Braillard’s medical records been reviewed, healthcare providers would have seen she was diabetic and required insulin. Around 8:00 PM that evening she was transported to the Estrella Women’s Jail. Affidavits provided by the inmates with Braillard state that her health appeared to decline on January 3^rd   and that she was not provided medical or nursing care.

On January 4, 2005 at 3:25 PM nursing staff was alerted by detention officers that Braillard appears acutely ill and is having a difficult time breathing. A nurse does not respond to the call for help until 4:55 PM, when records show some kind of medication being provided to Braillard. She is still not evaluated by a Registered Nurse at this point. (Licensed Practical Nurses are utilized to dispense medications at all the jail facilities.) Around 8:30 PM a friend comes to the Estrella Jail to visit Braillard but is advised she is too ill to receive any visitors. Concerned, two more friends initiate calls to the Estrella Jail at 8:45 PM to notify MCSO officers and nursing staff that Braillard is an insulin dependent diabetic who requires frequent medical care. Around 11:00 PM inmates report that Braillard begins vomiting. They attend to her while calling for help.

On January 5, 2005 at 2:45 AM Braillard is moved to an isolated area by corrections officers because she is “moaning too loud and keeping the other inmates awake.” At 7:00 AM that morning her daughter calls the Estrella Jail to again inform the staff her mother requires care for Diabetes that includes regular insulin administration. Inmates check on Braillard at 8:00 AM when she is discovered to be barely conscious. When the inmates try to rouse Braillard and get her up on her feet she falls forward onto the floor and has to be carried by inmates back to her bed—this event is caught on surveillance video. Braillard is finally taken via wheelchair to see the nurses in the jail’s clinic at 10:00 AM that same morning when nursing records show her blood pressure is extremely low and her blood sugar level dangerously high. EMS is not summoned until 10:25 AM at which point Braillard is shackled and taken to Maricopa County Medical Center where she slips into a coma. She remains in a coma, shackled to the hospital bed until January 23, 2005 when her daughter makes the difficult decision to discontinue her mother’s life support.

Discussion

I chose to write about Ms. Braillard’s death because I’ve had the opportunity to see first-hand the unethical practices that occur on behalf of *too many* of the nursing staff within the walls of the jails. I will write about those instances later, as this article was meant to be focused on just one of the many well publicized wrongful death cases involving the MCSO that went to court here in Arizona. I have a healthy belief (based on the court records I have read) that had the nurses involved in this case intervened sooner by advocating for timely transfer to the Emergency Room, Ms. Braillard might have lived. Nursing care should never be administered or withheld based on a nurse’s judgment about what a person has done or has been accused of doing prior to their contact with us— practicing this way goes against all that nursing was founded upon and all that the profession stands for.

Viewing the specialty of corrections nursing from a holistic and therapeutic perspective, I think that nurses are in a ripe position to impact the health of thousands –for the better—when seeking to advocate, by establishing a healthy rapport between the nurse and client, and providing thoughtful theory based nursing care in the corrections setting. We took an oath to adhere to our duty of protecting the health and wellbeing of the public—regardless of who they are or where they come from: “Men and women, mothers and fathers, sisters and brothers, sons and daughters, friends and family, and, too often, children are populating our correctional systems. They are all of us in some category or other, but they usually share one common denominator different from many of us on the ‘‘outside:’’ a history of poverty, neglect, and, in too many cases, abuse. Far too many others have the additional history of mental illness and/or substance dependency. They are vulnerable going in, and even more vulnerable coming out. Despite whatever offense they committed to put them in the system, these individuals remain members of our society who under the law do have basic rights”(Perez, 2009)  Last time I checked, there was no provision in the Code of Ethics for Nurses that advises us to “Titrate compassion, care, and professionalism based on your own judgment of the patient.”

The concept of justice is important to every human being’s health and wellbeing— and prisoners are no different:  “Meaningful access to justice for the individual prisoner is extremely important and its diminution is not a healthy development. It is at the core of the guarantee of adequate care. But, it also has a more direct effect on prisoners’ health. For an incarcerated person, the ability to have one’s legitimate grievances relating to serious mental or physical illness or suffering be heard by a federal court is a source of self-respect. And self-respect is both a necessary ingredient in the rehabilitative process and one that is hard to come by in the crowded, unhealthy, and often degrading conditions in which prisoners live.” (Wool, 2007) The events leading up to Ms. Braillard’s death should serve as a good platform for debate among nursing students everywhere, a robust discussion about the meaning of social justice within the context of nursing, as well as an exercise in the application of basic ethical precepts to the care we have a moral duty to provide ALL people in ALL healthcare settings.

Every specialty of nursing has its positives and negatives, but we all tend to “fit” somewhere. However, Corrections Nursing comes with a unique set of considerations nurses should take the time to mull over before attempting to care for patients in those settings. It isn’t for everyone. Prior to entering any specialty area it’s crucial to do some careful introspective work and figure out where your values and beliefs lie: “Personal and professional ethics influence the way healthcare providers interact with inmates. A solid ethical foundation for practice will assist in assimilating into the correctional environment while providing quality care. Maintaining a nonjudgmental attitude and focusing on the delivery of care are foundational components of correctional healthcare. Healthcare providers working in corrections must maintain an attitude focused on the human dignity of each individual regardless of lifestyle choices or past and present behaviors.” (Mathis, 2008) If your authentic self is telling you that remaining “impartial” is “impossible” then make the ethically sound decision to step away from Corrections Nursing as an option in your nursing career.

Resources

Braillard v. Maricopa County, Court of Appeals of Arizona, Division 2, Department B. (2010, May 27). Retrieved from FindLaw for Legal Professionals: http://www.leagle.com/xmlResult.aspx?page=1&xmldoc=In%20AZCO%2020100528027.xml&docbase=CsLwAr3-2007-Curr&SizeDisp=7

ABC 15. (2012, October 16). Retrieved May 7, 2013, from Taking Action: Key evidence in Maricopa County Jail death suit of Deborah Braillard ‘destroyed’: http://www.abc15.com/dpp/news/local_news/investigations/Key-evidence-in-Maricopa-County-Jail-death-suit-of-Deborah-Braillard-destroyed

ABC 15 . (2012, September 11). Retrieved May 7, 2013, from Taking Action: MCSO on Trial: A timeline of Valley mother’s final days: http://www.abc15.com/dpp/news/local_news/investigations/mcso-on-trial-a-timeline-of-womans-final-days

ABC 15 . (2012, September 10). Retrieved May 7, 2013, from Taking Action: MCSO on trial: Why a diabetic Valley mother didn’t have to die: http://www.abc15.com/dpp/news/local_news/investigations/mcso-on-trial-why-a-valley-mother-didnt-have-to-die

Mathis, H. &. (2008). Healthcare Behind Bars: What You Need to Know. The Nurse Practitioner, 33(5), 35-41. Retrieved May 7, 2013

Paz, R. S. (2007). Accomodating Disabilities in Jails and Prisons. In Public Health Behind Bars (pp. 42-50). Springer. Retrieved May 7, 2013

Perez, L. R. (2009). Vulnerable Populations, Prison, and Federal and State Medicaid Policies: Avoiding the Loss of a Right to Care. Journal of Correctional Health, 15(142), 142-149. doi:DOI: 10.1177/1078345808330040

Wool, J. (2007). Litigating For Better Healthcare. In Public Health Behind Bars (pp. 25-40). Springer. Retrieved May 7, 2013

It’s Time…

In just a few more days it will be time to say goodbye to someone I have come to love having in my life. Friday I set him free and on to the direction life is taking him— New York, the opposite side of the country. There are things that he needs to get done there. Despite us making plans for the future my heart has sensed…for the most part, that our time together was on the clock. But what do you do when love comes barreling into your life like he did mine? That first night he chased after me, grabbed my arm, whirled me around, and kissed me hard with both hands on either side of my face my heart was his. I fell in love with his sense of humor, his passionate Dominican temperament, his traditional ways, the loud and animated way he expressed himself, and his ability to love without limits.  When life comes at you like this do you think better of it and turn away, doing the safe thing….or do you embrace everything about the experience and relish all the stuff that comes with it? My daughter and my pack of dogs embraced him right away so I knew I just had to take a deep breath and jump.

      On our way to get take out for dinner tonight I was especially careful to enjoy every second of him playing with my long hair from the passenger seat, the moments he’d lean over to kiss my cheek or stroke my face, and every time he’d steal a hug and kiss the top of my head when we stood in line for our dinner at the Chinese place up the street. These will be some our last memories together.  Lord knows I’ve never been with anyone who was so affectionate and showered me with such attention, love, and care … The past few months we have shared together have been filled with a whirlwind of new experiences, crazy “shenanigans” and constant laughter. Yes, I am sad about the prospect of saying goodbye to someone so special and wonderful but in two years of trying to find my way through life I’ve learned that things appear on your path for all sorts of reasons…and we never know how long these gifts will remain in our lives to bring us joy.

I’ve been creating this mental scrapbook of sorts…recalling things about him, about us, that make me smile. Favorite songs that were “ours,” things he’d say or do that could make me burst into a fit of laughter on a bad day, stories about his life in New York.  I can honestly say I lived in the present every day and night we were together. Looking back, it’s probably the first time in my life that I have consistently done that.  In the dark, still hours of the night when he sleeps I lay awake wondering why he came along when he did, at a time when everything is in the process of turning upside down again…I ask God why he couldn’t have brought this amazing soul to me when all was well for my daughter and I…and why he can’t stay with us forever. I realize that I will never learn the answers to my questions, rather, I must be satisfied that for a few small precious seconds in time….during this devastating period of our lives…that the fates saw fit to deliver me such a blessing, a respite…or perhaps a reminder of what the other side of life is like—that there is more out there: More, color, brilliance, freedom, laughter, love, and peace than I could ever know. Maybe the reminder here, the miracle, is that I am just as deserving as anyone else in this world to have them…..

 

Monsoony Moments

“Living in the present” –I’ve heard it said that sometimes you have to take things one minute at a time, one hour at a time, and one day at a time. After a hot shower and pulling on my pajamas I sat outside in the courtyard with the pack, watching them play. Someone always has something that everyone else wants to get their mouth on or around….and every now and then one of the dachshunds would break free from the hunt, running laps around the fountain to disengage everyone else from the common quest of chasing after whatever coveted object one of them is keeping from everyone else.

It’s far from monsoon season, but tonight is a monsoony kind of night. Turbulent. There are patchy clouds overhead, rushes of wind that break through the branches of the big trees in both my yard and the next door neighbor’s yard… and frequent, fitful, flashes of lightening. For just a precious few moments nothing hurts. It’s a much needed break. I close my eyes and revel in the sensation of the cool breeze dancing on my skin and through my hair, smiling at the sweet sounds of the wind chimes tinkling in the trees. Resting my head back against the chair I decide to keep my eyes closed…. I like to pretend that the sound of the wind blowing through the trees is the waves crashing onto the shore of a beach somewhere far away from here.

In this dark place I set my soul free in a place that’s safe to twirl in the wind…to dance and play in the sand…until the sun comes up again and it’s time see reality– again. 

From The Mouths of Babes

…After an emotionally exhausting day of packing up some more, talking about my career with a good friend and colleague Vernon Dutton, and applying for at least 30 more jobs– my daughter shares her perspective with me while driving home from my parents house: “Mom, it’s time to let go. You can’t keep holding onto the pain anymore. You can’t continue to live and breathe this fight to get back to Nursing. It’s over. That part of your life is over and it’s time to move on.” I can’t adequately describe how the sting of those words felt and how they seemed to hang there between us until I finally hit the steering wheel with the palm of  my hand…objecting with three words: “No It’s not.” She tried to reason with me but thought better of it when the tears streamed down my face….We drove the rest of the way home in silence, each one of us going our own way when we arrived home….she– to her room upstairs, me to the kitchen for the nightly dachshund feeding ritual. Emmitt and Louie are so perceptive, perhaps because they have been with me the longest. I pick up each one of them, avoiding their eyes—because they always know when something is wrong. I hold both of them for a good long while, stroking their ears and talking to them as the others run around outside waiting for their dinner. I reassure them that everything is going to be okay. Somehow.

All I know is….she can’t be right. My daughter can’t be right.  Nursing has been my lifelong dream since the age of four. It’s all I have ever wanted to do in life. Being a mother and a nurse are all I know. It can’t be “dead…” It can’t be “over.”

Besides that, how on earth do you “let go” of something that makes up such a huge part of who you are–your soul?

It’s impossible.

That’s all.

Closing Time.

How does one take down a life? A life built on years of hard work, studying, hopes, dreams, and wishes whispered in the middle of the night? If there is some kind of rule book for the process  I’d like to find my way to it –and quickly. This is a different kind of pain. Tonight was the start of breaking down and packing away the home I worked so hard to provide for my daughter Anaya.  I smiled through hot tears as I heard her padding around upstairs, giggling and gossiping on the phone with her best friend since freshman year—Izzie.  It was a welcome reprieve– A sign of my daughter’s resiliency, evidence of her happiness with teenage life. That part of life went the way I had hoped and so carefully planned….my only child has had a phenomenal, happy, and balanced high school career. She came out exactly as I had dreamed she would….

I sat on the living room floor categorizing everything that made up the cozy home I created for her and my dachshunds—carefully labeling boxes for candles, photos, nursing books, tech stuff, craft thingies…..the list goes on. I decided to just go room by room, starting with the living room–our favorite part of the house.  The most difficult moment was when I took the college degrees off the wall, wiping each one down with a cloth before carefully placing them in a box. I remember the day that they went up. My father was so proud to do it because he had often talked about visiting my home someday and seeing my college degrees on the wall. He took a couple of hours measuring and repositioning them…finally standing back with a big smile when he was done. They hung on a wall right next to my study desk, which has sat empty now for a little over a year. Old textbooks and notebooks from my doctorate program are piled up and gathering dust, papers  are strewn everywhere, and the keys on the keyboard are stiff from sitting idle.

Ours is a life so interrupted.  I am trying not to see this transition as a failure on my part, though I am sure many would probably say that it is. I mean, I did do what I did. If I hadn’t, our lives would be so very different.  Happier. Stable. Full of possibilities. Perhaps I’d have my heart failure certification by now or be  presenting at major heart failure nursing conferences.   I’m not sure yet what the future brings….at this point I’d be happy to successfully get Anaya off to college and into the next phase of her life… Perhaps even find a measure of peace and comfort with mine. Every day I am not doing what is so very much a part of who I am is a painful one.  I wake up missing it. I close my eyes at night—missing it. I grew up wanting nothing more than to be a nurse, mother, and wife.  After two years I’ve concluded that there is nothing that can or will fill the void that is left inside of me. I wish it were as easy as leaving the pain behind in this big house that will soon be empty of life.

Behind Closed Doors #16: “That’s Not My Job.”

Information: Osonma. v. Smith, 2009-TX-0702.511 (7/1/2009)-TX

Summary: What was RN’s duty when Dr. did not order prophylaxis for Pt.?

 Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

     Mr. Martin, a 70 year old male, arrives with his wife to the hospital as a direct admission to the telemetry unit. He is going to be started on a new arrhythmia medication trial and it requires he be in the hospital for serial EKG’s for a period of two days. The Martin’s are assigned to your care, and as you are performing the admission assessment and gathering information about Mr. Martin you discover he has an artificial aortic valve. He also has a history for DVT and is a long time Coumadin patient. Immediately it’s apparent to you that he is at higher risk for developing clots because of his medical and surgical history. After entering all of Mr. Martin’s information in the computer you check his admission orders and are concerned when you realize there are no orders for Coumadin. You assume that the admitting physician, who has already interviewed the patient, has discussed this with Mr. Martin. It seems unusual, but drug interactions happen all the time–“Stranger things have happened…maybe the Coumadin doesn’t go well with this new trial medication they are starting him on today” you think to yourself. The doctors are always good about this stuff, so the irregularity in the order set for Mr. Martin is quickly pushed to the back of your mind as you close out of his chart and run to answer a couple of call lights.

The Real Thing

     BJ Smith was admitted emergently to Texas’s Methodist Hospital on November 25, 2006 when his right thumb had become amputated– he was 41 years old. BJ underwent hand surgery to reattach the thumb and was transferred to the Surgical Intensive Care Unit where he would be started on Heparin and Aspirin. As per usual for any patient admitted to a nursing floor, Mr. Smith had an admission assessment performed by a nurse on November 26, 2006. She identified that he was at high risk for DVT and PE.  Later that same evening BJ’s surgeon noted that complications had occurred necessitating the thumb to be permanently removed: “Dr. Pearson noted that the reattached thumb had undergone progressive venous congestion and arterial thrombosis.” The Heparin was immediately stopped and Mr. Smith was scheduled to undergo surgery the following morning.  Upon completion of the surgery he was admitted to a general medical surgical unit. This time around there were no orders written for the patient to receive anything for DVT/PE prophylaxis.

Mr. Smith began experiencing chest pain and shortness of breath late in the evening of November 26^th and he received oxygen to help alleviate his discomfort—to no avail. On the morning of the 27^th the surgeon consulted with another physician to help with the workup: “The EKG was abnormal, showed tachycardia, right bundle branch block, and Q wave abnormalities. The Doctor concluded that Smith’s pain was musculoskeletal and ordered that the oxygen be stopped.” (Tammelleo, 2009) On November 28^th Mr. Smith presented once more with symptoms and with a low oxygen reading—he was again placed on oxygen. On November 29^th he went into full cardiac arrest and died after complaining once more of severe chest pain and shortness of breath. It was later discovered that the cause of his death was a pulmonary embolus.

Questions for Consideration

1. Your patient is on a Heparin drip that needs to be stopped for a procedure. What is your role, if any, pertaining to the management of this drip?
2. Would a care plan have helped to identify and keep the risk for DVT/PE front and center in the care of Mr. Smith?
3. Was there a failure of nurses to advocate for Mr. Smith? Why or why not?
4. Name some common reasons why the need for Mr. Smith to be placed on DVT/PE Prophylaxis was missed by both medical and nursing staff

Discussion

     There are countless ways a detail like DVT/PE prophylaxis can get lost among the fast paced activities on a nursing unit. Various providers are coming and going at all hours of the patient care day, back to back admissions must be attended to, people require post-operative monitoring, patients  need to be ambulated and fed….the list could goes on forever. If you’ve been a nurse for any period of time you also know there are times that help in the form of patient care assistants is non- existent and the pleasure of running on call lights is yours alone to attend to. With high nurse to patient ratios and mandatory overtime in some areas of the country…it’s a tall order to expect a nurse to do it all without inevitably missing something. Depending on what is happening throughout any given shift it can be difficult to stay on top of completing admission assessments in a timely manner or being able to gather just the five or ten minutes it takes to sit, breathe, and commit the critical thinking necessary to evaluate each one of your patients for risks that could make the difference between a good outcome and a dreaded sentinel event.

It’s difficult for me to consider an opinion that assigns responsibility for an error like this to either the medical side or the nursing side. In fact Mr. Smith’s case screams out to me as more of a “system failure” requiring a thorough root cause analysis in order to evaluate where the holes are so that they can be patched up: “Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. The goal of RCA is thus to identify both active errors (errors occurring at the point of interface between humans and a complex system) and latent errors (the hidden problems within health care systems that contribute to adverse events). (AHRQ, 2012)

***FYI: Medicare dings your hospital each time sentinel events occur and your facility loses big money that way. Sentinel events are “Never Events.” You can read more about them on another blog I wrote by going here

Incidents like the one involving Mr. Smith highlight the need for a non- punitive just culture to exist in every workplace: “It’s a culture in which learning from disclosure is promoted while individual accountability for improvement is maintained. Moving toward a just culture requires that nurse leaders hold themselves and staff accountable as errors are disclosed. This accountability includes understanding why errors occur and identifying what systems, processes, and conditions are at fault.” (Voegelsmeier, 2007) Call me crazy (many people in the nurse blogosphere have) but I don’t view this tragedy as one where there seemed to be an intent to harm or violate ethics as I’ve read in other cases. Punishing people, firing them, stripping licenses away—none of that, in my opinion, belongs in a case like this. It doesn’t do any good to destroy more lives on the heels of a life being injured or lost. No one learns anything, nothing improves, and fear maintains its grip on the workplace. There is such an abundance of evidence based research out there supporting the fact that our work environments and the nature of what we “do” potentiate errors: “The healthcare system is vulnerable to errors because it is a complex and high-risk system (Braithwaite et al., 2009; Nolan, 2000; Wilson et al., 1999). A number of factors contribute towards the system’s complexity. First, healthcare involves complicated procedures and equipment. Second, healthcare involves interconnecting and interdependent components, for example different personnel from different departments are needed for a particular treatment. Any error committed by one component may affect other components as well. The effect of such errors is usually unpredictable; especially if the affected component is distant from the where the error originally occurred. Third, the system’s components are tightly coupled, so that an error in one component does not take very long to propagate to other components. Fourth, the healthcare system was designed and is operated by human beings, and human beings cannot predict all the possible effects of decisions or actions within the system (Christofferson and Woods,1999). (Taib, 2011)

       Corporate executives must not be allowed to escape responsibility when a tragedy takes place. If they want safer care, improved outcomes, and less sentinel events then the workplace must be set up to encourage and foster those things. This doesn’t mean just asking “What can nurses do better? What can doctors do better?” It’s also about holding the higher ups accountable and asking—“How can they improve the working conditions? How can they improve morale?” It’s devastating to see that any life has to be lost in order for everyone to stop the wheels from turning so as to examine what could have been done to prevent it.

What’s critical is that the questions are asked at all–silence can never be allowed to prevail.

Resources

Agency For Healthcare Research And Quality. (2012, October). Retrieved May 1, 2013, from Root Cause Analysis: http://psnet.ahrq.gov/primer.aspx?primerID=10

Taib, I. M. (2011). A review of medical error taxonomies: A human factors perspective. Safety Science, 49, 607-615. doi:doi:10.1016/j.ssci.2010.12.014

Tammelleo, D. (2009, July 1). The Free Library. Retrieved May 1, 2013, from What was RN’s duty when Dr. did not order prophylaxis for Pt.?: http://www.thefreelibrary.com/What was RN’s duty when Dr. did not order prophylaxis for Pt.?-a0206392137

Vogelsmeier, A. &.-C. (2007). A Just Culture: The Role of Nursin Leadership. Journal of Nursing Care Quality, 22(3), 210-212. Retrieved May 1, 2013

Behind Closed Doors Case #15: Making *That* Call

Information:Fearer v. Humility of Mary Health Partners, 2008-Ohio-1181 (03/14/2008) –OH

Summary: Operation success: patient died: deplorable care?

 Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

      It’s 0800 and word has quickly made it around the nursing unit that Dr. Dee is on call today for the general surgery service. On these days it’s harder to be a nurse because you have to think twice, or even three times before making a call for assistance with any patient assigned to him. Dr. Dee has been known to do more than just hang up on a nurse, in fact there have been numerous times you and your colleagues have gathered together as a nurse held the phone out for everyone to listen to one of his famous five minute freak outs. (they can be quite funny) On the not so funny days Dr. Dee has both yelled at and insulted nurses, throwing anything from pens to charts across the nurse’s station when something isn’t “just right” or if he deems a question asked by a nurse as inept or irrelevant for some reason.

     Bottom line–When Dr. Dee makes rounds your dressings better be changed, done the way he likes them, and your patients better be progressively ambulating. If not—your day and everyone else’s is pretty much screwed. Every nurse who attempts to page him after he’s had one of his blow outs is subject to the same treatment, if not worse. Then there are the golf days…  When Dr. Dee is on the golf course it’s a common practice among the nursing staff to accomplish whatever possible with one of his PA’s before even thinking to disturb him there.  Simply put, your patient better be crashing before using his direct pager on the golf days.

     On the Dr. Dee days the nurses on the unit try to pull together a little more to support whoever has one of his patients. Before a call is placed to the service, a nurse will often consult a couple of other more seasoned nurses to assist with clinical decision making before making a potentially ill -fated call that threatens to disrupt not just the morale of one nurse—but the morale of an entire unit. Today, it’s your turn to deal directly with “The Dee.”

     Mr. Arabia is 56 year old male who has just undergone an exploratory laparotomy. He is transferred into your care at 1500 from the PACU. According to the nurse’s report the surgery was unremarkable and the patient has been stable since waking up from anesthesia. Your initial assessment reveals a well-nourished and alert gentleman who appears younger than his stated age. Mr. Arabia is still groggy and reports some dizziness but he makes frequent jokes with you and the family members in his room. His initial blood pressure is a little low and the heart rate is a touch Tachycardic. Compared to the trends in the PACU there has been very little change. You make a quick call to the PACU nurse to ask whether Dr. Dee was notified of the low blood pressures and she replies that he left in a hurry for a fundraiser shortly after Mr. Arabia was transferred to her care from the OR. “I was too afraid to call so I just kept monitoring the patient and gave him a 250 cc bolus of saline to be safe.” she explains.

     At 1600 you check on Mr. Arabia once more. This time he appears slightly diaphoretic and is complaining of increased pain in his lower back and abdomen. A blood pressure reading reveals that both the systolic and diastolic blood pressures have dropped by another five points. His telemetry monitor is now showing a heart rate of 120. You begin thinking about calling Dr. Dee but decide to do some trouble shooting. You begin by helping Mr. Arabia to reposition himself in bed. You inspect his dressings, check for bowel sounds, and palpate the abdomen to assess for rigidness. He states that he feels a little nausea but that it seems associated with the pain. “Yes, pain is the answer” you think to yourself. If you can get the pain under control the heart rate will go down and he will be more comfortable. You ask another colleague to come and assess Mr. Arabia and she quickly agrees with your plan. “His blood pressure is probably still low from the anesthesia. Give it a little more time before you call Dr. Dee.” she advises.

     An hour quickly passes before its time to reassess Mr. Arabia’s pain. The Dilaudid has not helped and he looks worse than when you assessed him one hour ago. He is restless and his back pain has only gotten worse. His blood pressure is now below 90 systolic and his heart rate has risen to the 130’s. Stepping out of the room you dial Dr. Dee’s direct line to discuss the situation and obtain new orders to intervene on the low blood pressure. As you are explaining the situation he interrupts and unloads— loudly— in your ear: “What do you mean the blood pressure was low in the PACU? Who the f— bolused him without asking me first? Did you ever consider he could be having a f— retroperitoneal bleed? Why didn’t anyone f—  call me sooner with this shit? Why the HELL are you all there anyway? What is it exactly that you get paid to do? ” Dr. Dee continues on for a couple of minutes before giving you orders to immediately transfer the patient  to the ICU and informs you that he is on his way back to the hospital to take the patient back to the OR. Before hanging up he adds “This is not finished by a long shot. I will be contacting your manager about this do you understand? This was shitty nursing care and I plan on doing something about it!”

Taking a deep breath you slide the phone back into your pocket, lean back against the wall outside Mr. Arabia’s room and close your eyes for a moment while whispering to yourself– “Lovely.”

The Real Thing

       In September of 2000, 49 year old Raymond Fearer was admitted to St Elizabeth’s Health Center located in Youngstown, Ohio. He had elected to have a back surgery performed for chronic back pain. Aside from a liter of blood loss during the surgery, the surgery had been deemed successful.  Raymond remained hospitalized for two more days, which was a routine occurrence for a surgery like the one that he had undergone.

     The first signs of trouble occurred at 0430 on the second day of Raymond’s stay when his blood pressure dropped. According to court records the blood pressure was considered to be low enough to present danger: “The hospital nurse determined that the patient had very low blood pressure: blood pressure so low as to interfere with the blood flow to vital organs.” (Tammelleo, 2008) The physician was not notified about the low blood pressure at that time. When Raymond’s blood pressure resulted in a low reading a couple of hours later, the physician was called and the nurses were given an order to hold his usual blood pressure medication.

     Raymond summoned the nurses a little while later to report that he was feeling dizzy, a complaint that never made it from the nurse to the physician when he rounded on the patient at about 0825. The physician later admitted he had not taken the patient’s blood pressure himself, he didn’t look at the medical record, nor did he make any attempt to consult with the nursing staff regarding Raymond’s condition. He did, however, write orders for the patient to be discharged home that morning without any workup to discover the cause of the low blood pressure. With one final low blood pressure reading recorded at the time of discharge (and no call to the physician), Raymond was sent home with his wife.

     Mrs. Fearer contacted the physician later on in the day when Raymond continued to decline after being discharged home from the hospital. The physician advised her to being Raymond back to the hospital where he later went into severe respiratory distress. He was immediately admitted to the Intensive Care Unit where he was intubated, placed on a ventilator, and later died on October 6, 2000.

Questions for Consideration

1. Identify where gaps in communication occurred in this case.
2. How would nurse and physician rounding have prevented this poor outcome?
3. What role would Bedside Shift Reporting have played in promoting a better outcome? Be specific.
4. Do you feel we are responsible for making sure a physician makes contact with us as the primary nurse during rounds, is it the other way around, or does it go both ways?
5. Do you feel it your duty to make sure you have personally consulted with each one of your patient’s physician’s during the shift? Why or why not?
6. Define the concept of accountability as it pertains to this case. If you were to decide–who should ultimately be held accountable for the loss of life in this case?
7. Apply basic principles of ethics to this case (autonomy, beneficence, non-maleficence, justice, truth telling, and respect for persons) and identify where the patient and his wife fell short of having these fulfilled.
8. Were any provisions in the Code of Ethics for Nurses violated by the nurses? If so, which ones?

 

Discussion

     How many of us really want to call the doc and wake him/her up in the dead of night… or while they are trying to catch a little shut eye in the sleep room before rounds… or interrupt the “signing off” ritual when information on every patient in the hospital is being exchanged between providers at a rapid pace so the previous services can go home? My personal favorites are when you have to call providers while they are in the middle of enjoying a cocktail party or during a relaxing afternoon on the golf course. I don’t know about you, but I’ve gotten some of the most therapeutic collegial responses during those calls.

     Let’s be real here. We nurses know what happens when we inconvenience some of the providers out there—we get yelled at, insulted, or hung up on. The consequences of disruptive behaviors hasn’t escaped the watchful eyes of mainstream media, the Joint Commission, or The Institute of Medicine either: “The recent publicity given errors, patient safety, and risk management (the costs of litigation) collectively shed light on physician conduct and its impact on patient care.” (Pfifferling, 2008) At one recent hospital I worked at, the physician got so tired of me calling one night about the same patient I didn’t receive a call back at all when I placed an urgent page at 0630 (and several thereafter) because my patient was demonstrating full blown symptoms of stroke. Thankfully I documented every second and every minute of my care activities and the people involved in helping to get the patient to CT and to the ICU—WITHOUT the help of the primary provider.

     Before discussing this case any further, I should emphasize that I don’t know why the nurses failed in reporting two of the blood pressure readings to the physician. I have no clue whether the doc had a history of engaging in disruptive behaviors with the nurses he worked around. For the purpose of this article I focused on the well- known phenomenon of disruptive physician behavior as a factor nurses take into consideration when trying to make the all too important decision to “call or not to call.” It has a real impact on patient care outcomes: “The interplay surrounding disruptive behavior generates passive-aggressive and dysfunctional communication. The spiral of conflict and frustration promotes a toxic, sometimes lethal work environment. As noted in a previous publication, When physicians, management, and other caregivers tolerate disruptive behavior from a peer or team member, the patient is the loser. They may suffer, become wounded, or die. Patients with all diseases, for example cancer, are dealing with intense fears and feelings of loss and isolation. If their caregivers are emotionally unavailable and distracted by the actions or possible actions of a colleague, the patient’s isolation will be intensified. The real possibility also exists that important clinical or coordinated information will be missed because the attention of the team or partner is not where it should be.” (Pfifferling, 2008)  The truth is nurses learn, adapt quickly, and become pros at avoiding land mines wherever possible so as to maintain the peace in the workplace—and their sanity. This case has the real potential to be repeated when a variable such as disruptive physician behavior is allowed to remain unchecked.

     In the wee small hours of the night or during the moments leading up to a hospital wide shift change nurses tend to make those teeny tiny clinical judgments about what can or cannot wait for the next shift. You know you’ve heard this question before: “I mean, is the patient really that symptomatic?”  This case illustrates why it might be best practice to gather your wits about you, set fear aside for a couple of minutes, or stop rushing through end of shift tasks in preparation to go home (clocking out on time is not that important people), and err on the side of patient safety by making the call to the primary service involved in your patient’s care. None of us wants to be the recipient of disruptive behaviors in the workplace that leave us feeling like a random piece of lint on the carpet…but compared to carrying the responsibility of a patient injury or demise on your shoulders it’s a small price to pay for safety….and the preservation of your license.

Resources

Fowler, M. D. (2010). Guide to the Code of Ethics for Nurses: Interpretation and Application. Silver Spring, MA: Nursebooks.org.

Pfifferling, J. (2008, May-June). Physicians’ “Disruptive” Behavior: Consequences for Medical Quality and Safety. American Journal of Medical Quality, 23(3), 165. Retrieved April 28, 2013

Tammelleo, D. (2008, April 1). Operation success: patient died: deplorable care. Retrieved April 28, 2013, from The Free Library: http://www.thefreelibrary.com/Operation success: patient died: deplorable care?-a0178713107

Behind Closed Doors Case #14: Who’s in charge here?

Information: Wellstar Health System, Inc. v. Painter, S.E.2d -GA

Summary: GA: nurse insisted pt. “take” wrong meds: cardiac arrest resulted from OD on meds

 Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

Today is not a typical Monday morning on the telemetry unit. So far you’ve counted six nursing students milling around the nursing station nervously awaiting the 0700 shift report. “I hope none of them are mine” you think to yourself. Thankfully you’ve arrived earlier than your colleagues, gotten your assignment for the day, and have reviewed everyone’s history and physicals, labs, vital signs, and overnight telemetry trends. With about 15 minutes to spare before shift change you decide to head into the med room to pull everyone’s morning medications. Before long there will be a long line of nurses and nursing students waiting to pull medications from the Pyxis (taking up valuable counter space and time) and if there is anything you hate the most about the morning routine at work—it’s waiting. Especially when your plan calls for having assessments, medications, and charting completed before the medical and surgical teams hit the unit for their morning rounds with the nurses. You’re all about efficiency and having the information the doctors need the moment they ask for it. Appearing disorganized, unprepared, or clueless is not your MO. The med room is quiet and within minutes all your patients’ medications have been pulled from the pyxis, cross checked with the MAR’s, and organized into labeled Dixie cups that are lined up neatly on the counter. Satisfied that your pre morning routine is complete; you close your eyes, take a deep breath, and grab your coffee mug and KARDEX’s before heading out to the nursing station to take report from the night shift.

     

   While making your morning rounds and performing assessments you notice that the surgical service hits the floor nearly an hour and a half early for rounds. A wave of anxiety hits and your stomach cramps up as you rush to the med room to collect everyone’s medications. Surely you can get this part done before it’s your turn to round with the team. Making a beeline to the med room you nudge your way through the gossiping crowd waiting for their turn to access the Pyxis. When you reach the counter you quickly stack the Dixie cups on your clipboard and begin dispensing the medications. Five of the patients take the cups with a smile while eating their breakfast, but the sixth looks into the cup and shakes his head in confusion. “These look nothing like the pills I’m supposed to take every day.” You reassure Mr. Scott that you’ve checked everything over and that they have been ordered by the doctor. He empties the contents of the Dixie cup into the palm of his hand, picking through each pill and examining it. You’re getting really annoyed, thinking to yourself “Who went to school and got a degree to do this anyway?”

Mr. Scott breaks the now awkward silence: “I want to talk to my doctor before taking these pills ma’am, can you call him for me please?” Your staff phone rings just then and you fumble to pull it out of your scrub jacket. The caller identification shows it’s the surgical team. You need to get out to the nursing station ASAP for rounds. Quickly closing the patient’s door for privacy you respond hastily: “Look Mr. Scott, this is what I went to school to do, and what I get paid to do, to check these things over and get them right. These are your pills, your name is on the label, and they are what the doctor ordered. As your nurse I am insisting you take them right now.” Startled, he doesn’t bother to look at the label on the cup or ask any more questions. Dumping the handful of medications into his mouth he follows it with a gulp of orange juice. Appearing frustrated, he crushes the Dixie cup in one hand and tosses it into the trash next to his bed. Donning your best fake smile you thank Mr. Scott (who’s still grumbling under his breath) for taking the medication before leaving the room.

An hour later you’re seated at the nursing station wrapping up the last of the morning charting. Feeling more relaxed, you begin thinking about heading downstairs to the cafeteria for a midmorning snack. As you get up to find a colleague to watch your group of patients, the telemetry monitor alarms go off behind you.  It’s Mr. Scott. His heart rate drops from 80 to 50…then to 40 within seconds. Rushing to his room you find him slumped over the newspaper on his bedside table, the call light dangling at the side of the bed. Your coworkers call a code blue as you lower Mr. Scott to a flattened position in order to assess him. As you are doing this you notice that he is holding the Dixie cup in one hand. Curious, you take a quick glance and are horrified to find that the name on the label was not Mr. Scott’s after all…

 The Real Thing

      Early February of 2006 Michael Painter filed a lawsuit against Kennestone Hospital (Wellstar Health System, Inc.) located in Georgia. He alleged that during the third day of his hospital stay a nurse assigned to his care forced him to take pills that were not meant for him. Michael later described the incident with clarity recalling that “A nurse forced him to take three large cups full of pills. Each cup contained from six to ten different pills.” (Tammelleo, 2008) After objecting numerous times and requesting to speak with his physician regarding the pills, Michael finally took them when the nurse became upset with him stating “I’m in charge right now, and I’m telling you you’re going to take your medication.” (Tammelleo, 2008) He reports that the same nurse came back into his room a while later visibly disturbed, asking whether he had ingested all of the pills she brought to him. It wasn’t long before Michael became acutely ill, suffering a cardiac arrest that landed him in the Intensive Care Unit. Amazingly enough, he remembers observing and hearing a crucial conversation take place between the nurse who administered the pills to him and the nurse in charge during which an admission of error is made: “Before he lost consciousness Painter observed the ‘head nurse immediately fire the nurse who had forced him to take the medication. He allegedly heard the head nurse say ‘How could you have made such a mistake as this?’” (Tammelleo, 2008)

Questions for Consideration

1. Discuss the concept of power gradient and relate it to the relationship nurses have with their patients.
2. How can the use of power be used in both an ethical and an unethical manner when we care for patients or interact with our coworkers?  (Please refer to the Code of Ethics for Nurses)
3. Should a patient be “made to do” anything? Why or why not?
4. Did the nurse in this case go beyond her scope of practice at any point in this scenario? If yes, when?
5. Discuss the danger in the nurse’s thinking that “I’m in charge right now” and relate it to the popular models of care you hear the most about via evidenced based research—is this statement congruent to what you have learned? Why or why not?
6. There is one nursing diagnoses that could literally be used for every patient who enters the healthcare system. Discuss why it should be included in every patient’s care plan—every time. (Hint, the word “power” is involved)
7. What provisions of the Code of Ethics for Nurses did the nurse violate here?

 

Discussion

      You all probably think we’re going to get into the whole medication error discussion, but I don’t feel the need to dissect a nurse’s failure to perform the “5 Rights of Medication Administration.” That epic fail is what it is. We don’t know why she did it but she did. Case closed. This case is about much more than that.  For starters, let’s review a basic universal concept often applied in other situations where there is a question of power being imposed upon another human being: “No means no.” When a patient tells you to stop—it means cease what you are doing or saying and leave their room, and you do it NOW. If a patient is asking for their physician– you call them, no questions asked. Choosing to ignore or deny a patient that right places you into a dangerous area that may cross over into territory beyond your scope of practice. In this case, the nurse determined herself that the medications were the patient’s and that the physician was not needed to review the patient’s chart or make any further judgments. Yes, I know, that extra call to the doctor presents one of those annoying complications in the day– causing a few things on your “to do list” to wait on the ever elusive call back that always seems to come in the middle of something like a “Code Brown cleanup.”  Here’s some extra incentive: Want to boost the rapport between you and the patient? Call the doc right there in front of the patient if possible—it’s an instant trust builder.

 

This case study would not be complete without a discussion on some of the basic principles of healthcare ethics: autonomy, beneficence, justice, non- maleficence, truth telling, and respect for persons   —all of which the nurse in this case violated with respect to how she treated Mr. Painter.  Here are a few examples of how they are applied to Mr. Painter’s care: Mr. Painter’s autonomy was violated when he was denied the right to choose whether or not to take the medications, the nurse did not act with beneficence when she commanded Mr. Painter to take the pills without double checking them once more when he voiced concerns, He was denied justice when the nurse did not allow him to access and consult with his physician, and respect was most certainly withheld by the nurse when she declared “she was in charge here.” The nurse also violated the following provisions in the Code of Ethics for Nurses:

• Provision #1: The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. (Fowler, 2010)
• Provision #2: The nurse’s primary commitment is to the patient, whether an individual, family, or community (Fowler, 2010)
• Provision #3: The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. (Fowler, 2010)
• Provision #5: The nurse owes the same duties to self as to others, including the responsibility to preserve integrity, safety, to maintain competence and to continue personal and professional growth. (Fowler, 2010)

Please, if you haven’t done so already, invest in a copy of the Code of Ethics for Nurses here. Read it. Learn it. Use it. Teach it. There is a reason it exists.

When talking to nursing students I always like to refer to the AACN’s Interdisciplinary Model of Care (IMOC for short) because it incorporates a patient centered approach to care–not a “nurse centered one” that assigns all “power” to the nurse.  Whether we choose to recognize it or not, we are in a position of power because clients come to us in vulnerable physical and emotional states seeking various ends. The concept of power as discussed in a 2010 article written for Nursing Science Quarterly illustrates how easy it is to influence those in our care: “Power has historically been viewed from a position of dominance and authority. Using this lens leads one to a destiny wherein one individual or society has power over another. The power over approach is a hierarchical view, one that leads to someone else being oppressed, and one wherein the prevailing hegemony continues.”(Polifroni, 2010)   A 1999 article published in Ethics and Behavior discusses the role of a power imbalance within the realm of clinical psychology. These same principles can also be applied to our relationships with patients in just about every healthcare setting: “Power imbalances can be exacerbated by the sociodemographic characteristics of psychologist and client (Cooke & Kipnis, 1986; Sonne, 1994; Sutton, 1997), the competence of the psychologist, and the nature and degree of clients’ distress and need for help (Owen, 1995). Much social psychology literature bears indirectly on power processes in clinical psychology (e.g., Fiske, 1993). For example, there is evidence that stereotypes can powerfully describe and explain a person’s experience and behavior (Fiske, 1993). Although based largely on controlled analog experiments, Fiske (1993) suggested that when there is a power imbalance, such stereotypes can become self-fulfilling prophesies, because the powerless attend carefully to the messages of the powerful for cues about feelings, thoughts, and behavior.” (Kuyken, 1999) Like it or not we possess an “invisible tool” of sorts, one that must be handled therapeutically, ethically, and responsibly so that the patient is always protected, given as much power as possible, and kept at the center of their healthcare.  If you have a problem with those basic fundamentals or adhering to the Oath and Code; please do everyone a favor, step away from the patient…. and let a real nurse do the job.  

Resources

Cour of Appeals of Georgia. (2007, November 29). Retrieved April 27, 2013, from FindLaw For Legal Professionals: http://caselaw.findlaw.com/ga-court-of-appeals/1003807.html

Wellstar Health System, Inc. v. Painter. (2007, November 29). Retrieved April 27, 2013, from Find a Case: http://ga.findacase.com/research/wfrmDocViewer.aspx/xq/fac.20071129_0001783.GA.htm/qx

Fowler, M. D. (2010). Guide to the Code of Ethics for Nurses: Interpretation and Application. Silver Spring, MA: Nursebooks.org.

Kuyken, W. (1999). Power and Clinical Psychology: A Model for Resolving Power-Related Ethical Dilemmas. Ethics & Behavior, 9(1), 21-37. Retrieved April 27, 2013

Polifroni, E. (2010, January). Power, Right, and Truth. Nursing Science Quarterly, 23(1), 8-12. doi:10.1177/0894318409353811

Tammelleo, D. (2008, January 1). GA: nurse insisted pt. “take” wrong meds: cardiac arrest resulted from OD on meds. Retrieved April 27, 2013, from The Free Library: http://www.thefreelibrary.com/GA: nurse insisted pt. “take” wrong meds: cardiac arrest resulted…-a0174239570

 

Behind Closed Doors Case #13 The Dangers of Nurse Defamation

Information: Alterra Healthcare Corp. v. Campbell, 2D10-4444 (11/9/2011)-FL

Summary: Nurse awarded over $500,000 in defamation suit

 

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

 

     The brand new hospital you are starting at tomorrow morning is stunning. In fact, you’ve dubbed it the “Titanic” of hospitals. Valley Vista Medical Center: from the freeway one can see it standing proudly;  like a posh, modern, Las Vegas  hotel on the strip complete with windows that sparkle in the Arizona sun during the day–while masquerading as a turquoise and copper architectural piece of art when lit up at night.  The tour of the hospital’s interior revealed stunning contemporary  décor from floor to ceiling and advanced technologies well established to enhance patient care delivery.  You feel more than lucky to have been hired on here.  Unbeknownst to you,  this is where the short love affair with Valley Vista will end.

     Lack of teamwork, betrayal, backbiting, bullying among the nursing staff, tampering with staff Pyxis credentials and narcotics, chronic staff shortages, high nurse to patient ratios, abusive physician behaviors, and a constant struggle to get your hands on the supplies and equipment to do your job are just the start of the nightmare. You’ve also got a charge nurse (more like charge monster) who has made it abundantly clear to you (as well as to the nurses you work with) that your “brown skinned self will not make it past orientation if she has anything to do with it.”  To top things off, the charge monster reminds you regularly that “you are on your own.”

     The Queen Bee has some “favorites” surrounding her at all times throughout the shifts and you’ve overheard plenty of the scheming to “get rid of this Bitch.” (the “Bitch” being yours truly) The “Plan” includes telling the nurses not to help you with any patient care or tasks should you ask for any assistance from them. The most dangerous of her ploys: she ignores your pleas for help to get your Pyxis credentials fixed. Because they work only maybe one time out of ten, you aren’t able to give medications on time to any patients and they ring the call lights constantly—angry, in pain, and demanding to complain to management. Her solution is advising you to ask the other nurses to sign you in and out of the pyxis because she “has other things to do.” Horrified and frustrated, you send several emails to the Nursing Director of the unit and to the House Supervisor about the problem but for some reason your requests for intervention have fallen on deaf ears. Your conversations with the pharmacy staff (who are located on the other side of town) yield bewildered responses— they’ve never seen anything like this problem occur with any nurse previous to you. Of course they haven’t.

     New on staff and afraid to make waves you do your best to keep your head down, avoid The Bee and try to find ways to get the scheduled medications passed when the other nurses are able to sign you into the Pyxis with their credentials. It’s bad enough you are always the last nurse making rounds, and the last one to sit down and chart but you carry an additional burden – worrying about the odds against you. Any day now there could be a medication discrepancy involving one of the nurses yet you try you continue to remain hopeful the Pyxis debacle will be resolved.  Unfortunately, this will never happen.

     Two weeks into your employment the Queen Bee and the Nursing Director call you in for a meeting on a day off. The Bee is prepared with numerous accusations (delivered in a cooler and crispier than usual British accent) that target your “rude behavior, lack of professionalism, failure to work within a team, patient complaints, and lastly—her suspicion that you are pocketing narcotics. It’s of no surprise to you that when you inquire about the names of people complaining or dates and incidents she is unable to provide you with this information.  The Bee has also taken the liberty of creating a word document (she’s sweet enough to provide you a copy) of all the narcotics discrepancies you have been involved with and is more than thrilled to offer her accounting of your supposed drug heists.

     Seated in a chair across a conference table from the two of them you maintain a stunned silence. These absurdities aren’t true. Your coworkers know these things aren’t true. Glancing back and forth between the Director and The Bee it’s easy to see who is running the show here. The contrast between the two is quite remarkable. The Director appears tired, frumpy, wearing mismatched and wrinkled scrubs, looking like she’d rather be doing a hundred other things than attending this little soirée. The Bee, on the other hand, is nothing less than demure in a stylish, all black bohemian type ensemble. Her dirty blonde hair is neatly smoothed back into a bun that accents her piercing blue eyes, and she has one leg crossed revealing high healed stiletto boots.  “Lethal” you think to yourself… “She came prepared.”

     During these fatal moments it becomes crystal clear that you never stood a chance and should have done something earlier to protect yourself, your professional reputation, and your license. With disgust you note the sickening, satisfied gaze of The Bee as she gingerly…and with one graceful well-manicured finger, slides some forms in front of you to sign. You meet her icy gaze head on…. and realize it may be too little too late.

The Real Thing

     Michelle Campbell began her short tenure as a Registered Nurse at the “Alterra’s Care Bridge Assisted Living Facility” in March of 2002. Fancie Cales was both her nursing supervisor and the facility’s health care coordinator. It didn’t take long for Michelle to realize that any chance of establishing a professional or civil working relationship with her supervisor would never come to pass. She quickly resigned and sought employment elsewhere, signing on with a nurse staffing agency by the name of Maxim Healthcare who dispatched Michelle to a nursing shift at “Sterling House,” which was within the Alterra’s family of facilities. It was in May of 2004 when the Sterling House Residence Director, Erick Flock, called Maxim for an agency nurse to cover a 3-11PM shift. He was unaware of Michelle’s previous history with Miss Fancie.

     Whether it was “Fate” or “Karma” that had a hand in what was to come–Michelle and Miss Fancie would soon find themselves reacquainted. Fancie Cales was now a nursing supervisor at the facility Maxim had sent Michelle to. When she arrived for the appointed shift, Miss Fancie immediately approached Mr. Flock and insisted that Michelle be cancelled off of the shift. According to court documents “Fancie told him that she had worked with Michelle at another facility and that she was bad news. She also told Flock that Michelle had been suspected of stealing narcotics from that facility.” (The Free Library, 2011)  Mr. Flock would not send Michelle home that day, stating that if he were to do so Fancie would have to cover the shift herself.

     The established procedure at Sterling House was for the oncoming nurse to conduct a medication count with the off going nurse. Per Michelle’s recollection, everything was routine and the shift proceeded as normal. Medications were sorted, stored, and secured as follows: “Most of the medications were prepackaged in blister packs for ease of dispensation and control. The blister packs were stored in a locked, removable box that itself was stored inside a locked medication cart. The door to the nursing station would automatically lock whenever a nurse or medical tech left the room.”(The Free Library, 2011)  In order to access the nursing station, the med box, or the med cart one must use a specific set of keys made for each one. Normally, three people are assigned the keys on each shift: the nursing supervisor, a pharmacist, and a Registered Nurse (or if licensed to give medications—a medical tech). During the shift in question Miss Fancie approached Michelle and asked to use the keys in order to access the nursing station for patient charts. She quickly returned them to Michelle without incident. Another unnamed employee was also given the keys, by Michelle, on various occasions throughout the same shift in question so that they could obtain supplies from the nursing station.

     As part of the “end of shift duties” Michelle engaged in another medication count with an oncoming medical tech who noticed that some of the blister packages may have been tampered with. Michelle signed off on the count in the log book, assumed the medical tech had as well, and turned over her set of keys to the tech before leaving the facility. Her recollection of events is as follows: “Michelle stated that they discovered a medication error resulting from one of the patients receiving the wrong dosage of medication. Michelle asked the tech to call a supervisor to discuss the incident reporting procedures. Michelle left a message for Fancie on her voicemail.” (The Free Library, 2011) She later recounts that after working through and resolving the discrepancy with the tech the medication count concluded as it normally would.

     Two days later Michelle would learn that the situation was much more serious than she could ever imagine: “Maxim notified her that hydrocodone and oxycodone pills and oxycodone pills had been switched out for other pills in some of the blister packs. She was arrested and charged with repackaging an adulterated or misbranded drug, trafficking in oxycodone, causing a drug to be counterfeit, obtaining a controlled substance by subterfuge, and furnishing a false controlled substance form.”(The Free Library, 2011) To add insult to injury, Maxim fired Michelle without question or further investigation (another great place to work huh?) —Sadly, according to case documents, there were no attempts by the agency to advocate on her behalf.

     Karma…Justice…whatever you want to label it, prevailed in this case. Michelle sued Alterra for “malicious prosecution.” The trial jury determined she was innocent and ordered that she be awarded a total of $539,657.00 in both compensatory and punitive damages. During the course of the investigation it was discovered that before Michelle ever stepped foot into the doors of Sterling House there had been an average of “five drug thefts a month.” I wonder what Miss Fancie has to say about omitting that little detail when both she and Flock made statements to investigators that no previous incidents had occurred before Michelle’s shift at the facility?

***Interested in the Court’s official opinion?***

     “The court held, inter alia, that there was no evidence upon which a jury could rely in finding for the defendants. The court noted that even if the defendants could not have known the information given to authorities was false at the time it instigated proceedings, surely it should have known that the information might have been false once the drug thefts continued after Michelle was fired. Further the court noted that although Flock attempted to report one subsequent drug tampering/theft incident to the detective assigned to Michelle’s case, he never reported the incident involving another employee whose drug screen was positive, despite the fact that the same employee worked shifts just prior to Michelle’s  on the day in question. The court noted that Flock also failed to report either incident to Michelle, her attorney, or the State’s Attorney’s Office. Such information might have resulted in dropping the charges at an earlier point in time.” (The Free Library, 2011)   

Questions for Consideration:

1. Is there anything Michelle could have done better at the time the drug discrepancy was discovered? If so, what?
2. There is an inherent danger with keys being assigned to staff members during a shift. What would you do to assure that your license is protected when assigned keys at a facility such as this?
3. In your opinion should Michelle have been fired right away from the nursing agency and should they have advocated for one of their staffers?
4. Two agencies are mentioned within the case study, what have you as a nurse learned about being selective with regard to where you accept employment?
5. What provisions of the Code of ethics for Nurses did Miss Fancie violate?
6. What does defamation of character mean to you? Does it happen just in the workplace, if not where else have you seen it occur?

Discussion

     Make no mistake, we practice during a volatile time in our profession’s history. The stakes are high as corporate entities continue to push nurses beyond their capacities to perform—not in the name of patient care, but in the never-ending quest to achieve the ever elusive highest levels of customer satisfaction in this profit driven industry. So, just how bad is it out there? A recent article in the American Journal of Nursing cites a study that states “Of more than 95,000 nurses(the study)finds that direct care nurses in hospitals and nursing homes, who are often considered the first line of defense in patient care, are significantly more likely to be dissatisfied with their jobs (24%and 27% in hospitals and nursing homes, respectively) and to describe themselves as burned out(34% and 37%, respectively) than nurses in non- nursing jobs or jobs not involving direct care (of whom13% are dissatisfied and 22%burned out). (McHugh MD, 2011) The reality is we are asked to achieve the impossible in work places that are toxic and unhealthy. These work environments take the form of fast paced, high acuity nursing units or skilled nursing facilities with dangerous nurse to patient ratios…The icing on the cake is practicing within a right to work state, where a nurse can get fired simply for the color of his/her hair.

     So what is a nurse to do these days?  The questions that we as nursing professionals should be asking ourselves and each other is: “Where do our interests, safety, and satisfaction come in to play? Who is looking out for us?” The answer to that is easy: When it comes to Corporate Nursing you are your own best advocate and no one will look out for you, your interests, or your career better than you.  This case illustrates the importance of not settling for negative work environments, remembering that we have the prerogative as professionals to pursue positive and supportive workplaces, exercising greater discretion when voicing our opinions about colleagues, paying attention to detail, never making assumptions, and arming ourselves with a good nursing liability insurance policy.  Familiarizing oneself with an experienced nurse attorney who knows the ropes when it comes to the unique complexities of defending nurses in cases like the one above, or before any State Board of Nursing should also be on that list of things we can all learn from Michelle’s case: “Nurses should thoroughly question any attorney they are thinking of hiring to ensure that the attorney has the proper experience and knowledge to practice before the Board. The area of law that involves regulatory agencies such as the Board of Nurses is called Administrative Law. Nurses should look for an attorney that is Board certified in administrative law and one that frequently represents nurses before the Board. Nurses should not assume that every attorney has the knowledge or the experience to adequately represent them before the Board.” (Mackay, 2011)

I should know…

      Since I’m headed *there*…we might as well talk about it. How does a nurse go about finding the right attorney to defend him/her? Calling the first attorney you settle on via an internet or phone book search can make or break a case outcome and the status of your nursing license. (So put down the iPhone or phone book, have a good cry, hit a wall, then take a deep breath) I acted hastily and it cost me dearly. One attorney I met with and chose to assist me misrepresented themselves by telling me they had defended 60 or 70 nurses before the State Board of Nursing in Arizona. When I did some investigating it turned out that they had only been before the Board less than five times in over  year and were actually new to defending nurses before the Board. In addition to this, they failed to take some very crucial steps necessary to protect me and my interests during one of the most important parts of my case.

     Since I went *there*…I might as well stay on topic. Here are some tips to consider acting on in order to ensure you and your license are protected at all times: 1.) Take a break from Facebook and devote a few minutes to browse through your local State Bar’s website. Become familiar with your rights as a client upon entering the client/attorney relationship. 2.) Look up The American Association of Nurse Attorneys website and give them a call for a listing of nurse attorneys they recommend in your area. 3.) Keep the information handy in a folder marked NURSE LIABILITY INSURANCE POLICY. Too many nurses feel they will never need this protection. If you don’t already have a policy…GET ONE…and do it NOW. “There are many reasons why nurses do not purchase this inexpensive protection. For example, some nurses believe that an employer’s insurance will take care of any problems. However, the employer’s insurance may not completely cover the damages and it usually does not cover actions before the Board. Furthermore, in a situation where the employer reports the nurse to the Board, the employer is not going to then spend money defending the nurse.” (Mackay, 2011)  Nurses Service Organization has long been recognized as a reputable company of choice by many nurses, so consider carving a few more minutes out of your Facebook/Pinterest/Tumbler/Twitter life to check them out and make the purchase. A policy costs no more than the money that many of us spend at Starbuck’s each month. 4.) When it comes to workplace disciplinary measures: DO NOT SIGN ANYTHING if you are unsure of what it is you’re signing or if you disagree with it!—Retain copies of any and all documents and always contact an attorney for advice before you say or sign anything you are hesitant about.

     In hindsight I think we can all recognize the prudence of looking two or three times to make sure a process is complete BEFORE we swipe that badge to go home—the consequences of failing to do so are tragically evident in Michelle’s case. If someone is supposed to co-sign equipment or medication counts with you, stand there and make sure they have done it.   If you start an incident report, finish it. Is there any rule floating around out there about snapping a picture of it with your iPhone as proof you did it??? (We all know how these disappear into thin air later and everyone says it was never done) Can’t reach management? Keep calling until you get the supervisor on the phone so that an incident can be resolved before you leave the workplace. Move through the chain of command until you find the right person to resolve it right there and then. Lastly, if you work for an agency like Maxim, be proactive before signing on with them or accepting assignments– ask the recruiter what the policies and procedures are in a case such as this. Will the agency advocate for you and give you a chance or will they leave you out in the cold at the word or accusation of a third party? If they cannot provide assurance that they will stand by you as an employee until they hear your side of a dispute or until/ if you are proven guilty, strongly reconsider accepting employment there. Nurses are not used Kleenex or old paper towels to be tossed out at will.

     Nothing about this case resonated with me more than the sheer audacity and will of one nurse to assume she has the power to stand in the way of another colleague making a living within the profession by destroying their public image and reputation. When revisiting the Code of Ethics for Nurses its clear to see Miss Fancie’s little routine may have violated these provisions:

• Provision #1: The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.(Fowler, 2010)
• Provision #5: The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence and to continue personal and professional growth.(Fowler, 2010)
• Provision#6: The nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality healthcare and consistent with the values of the profession through individual and collective action (Fowler, 2010)

     Now, if you are one of *those nurses* that enjoys coloring outside the lines of your colleagues’ reputations at work or someone who doesn’t play nicely in the social media sandbox by throwing mud pies or Molotov cocktails over the world wide web, you’d do well to brush up on the Code of Ethics for Nurses as well as the definition of “defamation of character” and how it applies to you and your artwork: “Most jurisdictions also recognize ‘per se’ defamation, where the allegations are presumed to cause damage to the plaintiff. Typically, the following may constitute defamation per se: Attacks on a person’s professional character or standing, allegations that an unmarried person is unchaste; allegations that a person is infected with a sexually transmitted disease, allegations that the person has committed a crime of moral turpitude.” (Larson, 2003) As social media continues to evolve and further entrench itself into the norms of everyday life,  new laws are being created to stave off the personal and professional damages suffered by others as a result of your extra-curricular activities. If you’re not more careful, it may be your license that is placed in jeopardy someday—at your own hand no less…and we all know– Karma can be a real bitch. 

Resources

Case On Point (2011, November 1). Nurse awarded $500,000 in defamation suit. Retrieved April 24, 2013, from The Free Library: http://www.thefreelibrary.com/Nurse awarded over $500,000 in defamation suit.-a0323859095

Fowler, M. D. (2010). Guide to the Code of Ethics for Nurses: Interpretation and Application. Silver Spring, MA: Nursebooks.org.

Larson, A. (2003, August). Defamation, Libel, and Slander Law. Retrieved April 23, 2013, from ExpertLaw: http://www.expertlaw.com/library/personal_injury/defamation.html

Mackay, T. (2011, 11 22). Protecting Your License From The Nurse Police. Retrieved April 24, 2013, from Nursetogether: http://www.nursetogether.com/protecting-your-license-from-the-nurse-police

McHugh MD, e. a. (2011, May). Nurses’ Job Satisfaction Linked to Patient Satisfaction. American Journal of Nursing , 111(5). Retrieved April 15, 2013

Behind Closed Doors Case #12 Nurses & Jury Duty: Disaster?

Information: Ledbetter v. Howard, 2012 OK 39 (4/24/2012)-0K

Summary: Caveat for Nurses Serving as Jurors in Cases Involving Medical Care

 Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

     It’s late and you’re tired from an exceptionally long fourteen hour shift…you go ahead and settle the debate that’s been going on in your head since turning the corner into the neighborhood by checking the mail instead of ignoring it another day. As you walk into the house, flipping through junk mail and the latest installments of your favorite magazines– a few pieces of mail fall to the floor. One of them looks familiar; you’ve seen it before….. It’s a jury summons. Groaning, you toss the pile of nonsense onto the kitchen table and head to the laundry room where you change out of the now offensive clothing you are wearing and into “non- bio-hazardous” materials. After a hot shower and one more trip to the kitchen for a snack you take a quick glance at the jury summons to determine what date you must appear. Next week is good. There’s plenty of time to notify the nursing manager at work to help fix the schedule so you can still get all your work hours.

     Initially dreading any notion of sitting on a jury you find yourself excited because it’s a case involving some type of medical malpractice or negligence. You’re actually surprised to be on this jury given that you did everything but scream out in open court that you are a Registered Nurse and therefore cannot be spared for a lengthy period of time to participate in a trial. The first day you and your jury mates meet they select you as the foreperson and now it’s time to settle in and get the show on the road. This isn’t some murder trial so it couldn’t possibly take any more than a couple weeks to resolve, right?

Eight weeks later you’ve had your fill of this whole jury experience and you’re ready to be done with it and go back to your own little “nursey corner of the world” where you go “do your three and your free for four.” The deliberation process has been painful to say the least because you know based on nursing and medical knowledge that the people filing the lawsuit against the hospital are lying in several key areas of the case. Right now the jury is split and you as the foreperson are not budging. This case cannot be found in favor of the people suing the hospital—too many things just don’t match up to what you know of the processes and procedures that take place in a routine cardiac catheterization patient care scenario that you’ve seen or been a part of at least a thousand times in the past couple of years alone. So you impatiently sit, sulk, and let the others hash it out—you’ve made your decision. You’re a nurse. You know more than them anyway.  

One more week goes by and the combination of fatigue, frustration, and impatience with the whole trial process takes over your sensibilities. You’re way over your limit of patience when it comes to hearing the members of the jury discuss and debate the same things over and over. It’s 1900 hours on a Friday night when you stand, hold your hands up, and tell everyone “That’s it. Everyone listen up. You want proof these people are lying? Here’s what I know and here’s why you should vote in favor of the hospital. Let’s all be done with this so we can get back to our lives shall we?”    

The Real Thing

     Guy Ledbetter, a long time diabetic, began suffering from the effects of peripheral neuropathy sometime between 1997 and 1998. In May of 2005 he developed some redness, swelling, and general discomfort in his left lower leg and foot. He sought medical care from his primary care physician Dr. Kevin Reed. Several consults, antibiotic rounds, x-rays, hospitalizations, one external fixator, long term cast, and a specially crafted boot later it was discovered (during another set of x-rays ordered by his primary care physician) that the bone had deteriorated significantly in Mr. Ledbetter’s left foot. Mr. Ledbetter and his wife would later file suit (citing loss of consortium) against the physician who initially interpreted the first foot x-rays to be unremarkable alleging that the error contributed to delayed treatment of the foot. The initial judgment of the jury was for the defendants. The Ledbetter’s would request a new trial based on the fact that the jury foreperson was a Registered Nurse who was later found to have utilized her professional knowledge to sway jurors toward a favorable judgment for the defendants. A written affidavit from a member of the jury supported the allegations made by the plaintiff’s side. According to court records “The facts were that on voir dire the jury foreperson, a nurse, assured the court she would not allow her expertise and experience as a nurse to override the evidence presented during the trial. However, she not only did soon a personal level but went further by communicating her alleged professional knowledge and experience to the other jurors with the deliberate intent to sway their votes in favor of the defendants. However, since a juror submitted an affidavit that the nurse tried to influence the outcome in favor of the defendants, the Court of Civil Appeals determined that the juror’s affidavit was admissible under the “extraneous prejudicial information’s exception. The court ordered a new trial for the plaintiffs.” (Tammelleo, 2012)  The Supreme Court of Oklahoma agreed that the attempts of the jury foreperson to use her medical and nursing knowledge to sway the outcome of the case warranted the new trial.

Questions for Consideration

1. Should nurses ever be included in a jury when any aspect of healthcare is involved?
2. Discuss the different pieces of the Code of Ethics for Nurses. What were the nurse’s responsibilities to the profession during this case?
3. What were the nurse’s responsibilities to the community throughout the continuum of this case?
4. It was never discovered whether or not the nurse had to face any discipline before the State Board of Nursing. Should she have had to answer for what happened? Should she have been disciplined?
5. Had the nurse foreperson kept her nurse credentials and experience under wraps would she still be wrong in allowing professional knowledge and experiences to influence her decision making in the case as a member of the jury? How is this a potential violation of ethics?
6. Was there harm done to a patient by a nurse in this case? If so, how?

Discussion

     There are nurses who view what they do as a “job” and then there are those of us who believe and embrace nursing as more of a “calling” and a lifelong commitment to the advancement and improvement of the profession. The differences between those two schools of thought are pivotal. In my mind there are no “50 shades of nursing.” You either embody what Nursing “is,” making it a part of who you are as a person and by setting the right example— or you detach from it with the swipe of an ID badge at the beginning and end of a shift with the belief that your obligations as an RN end when twelve hours are up. Either way you choose to go, there are a few things that you should know about what comes with the credentials “RN” –and they apply to nurses on both sides of the camp.

     One of the “imperatives” that come with being a Registered Nurse is the obligation we have to act in the best interests of not just our patients, but with the best interests of the community and the profession in mind as well. For you nurses who like to leave the “nurse at work,” this case is a not so subtle reminder that a nurse is a nurse no matter where you go outside of work. What we say, how we look, how we act, how we present ourselves—are deciding factors in how the public perceives our work and our profession as a whole. They make up the foundation of the public’s trust in us as healthcare providers. The nurse in this case violated not just critical pieces of the Oath, but several provisions of the Code of Ethics for Nurses. One of the earliest versions of the Code states: “The nurse should carry out professional commitments and activities with meticulous care, with a generous measure of performance, and with fidelity toward those whom she serves. Honesty, understanding, gentleness, and patience should characterize all of the acts of the nurse….the nurse has a basic concern for people as human beings, confidence in the fundamental power of personality for good, respect for religious beliefs of others, and a philosophy which will sustain and inspire  others as well as herself.” (Fowler, 2010)

Voluntarily adhering to the Code as a personal value in the day to day business of living is one matter in and of itself, but in this case the nurse openly identified herself as a “Registered Nurse” which thus heightened the importance of placing the Oath and the Code front and center to how she conducted herself among members of the community and as the jury foreperson. She used the power of her professional knowledge to skew the outcome of a trial which ultimately endangered the public’s trust and the trust of the legal system. The court affidavit established that the nurse acted intentionally, which violates the following provisions within the Code of Ethics for Nurses (keep in mind that the “patient” is the “community”):

• Provision #1: The nurse in all professional relationships practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual.
• Provision #2: The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
• Provision #3: The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
• Provision #5: The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety and to maintain competence.

   (Fowler, 2010)

     When the nurse became aware that there were aspects of healthcare involved in the case she would be participating in she should have withdrawn from the jury assignment citing conflict of interest. This action would have been the ethical thing to do and would have been congruent with the Code of Ethics Provision #2 (Interpretive Statement 2.2):  “Nurses must examine the conflicts arising between their own personal and professional values and strive to resolve such conflicts in ways that preserve the professional integrity of the nurse. Nurses should disclose to all relevant parties any perceived or actual conflict of interest and in some situation should withdraw from further participation.” (Fowler, 2010) This is not the first trial that has been disrupted from a Registered Nurse sharing inappropriate knowledge or information that tainted a jury’s decision making capabilities.

     In the case of People versus Maragh, (2000 N.Y. LEXIS 899) a new trial had to be ordered because two nurses who sat on the jury used their professional knowledge with members of the jury as part of the deliberation process. The defendant was being charged with the murder of his girlfriend (based on evidence the prosecution presented) that was consistent with “blunt force trauma to the victim’s liver and spleen, with massive internal bleeding.” The defense responded with expert testimony via the autopsy results which concluded that the victim suffered from air emboli secondary to seizure activity in conjunction with a cardiac event. The defense would later lose their case, but soon after its conclusion two jurors stepped forward to report that the nurses on the jury casted doubt on the expert testimony by offering their professional opinions: “Another juror, a registered nurse, had informed the jury that, contrary to the expert testimony for the defendant, ‘in her medical experience and estimation, the reported volume of the victim’s blood loss could have caused ventricular fibrillation, which would result in death.’ There was also evidence that a second juror, also a nurse, ‘performed personal estimations of the blood volume loss and shared them with the rest of the jury.’ One of the lay jurors also testified that the jury’s verdict had been directly affected by the nurses’ opinions.” (Ewing, 2013)

     It’s hard to say for sure whether any nurse can sit on a trial jury without letting his or her professional knowledge and experiences get in the way of making a personal decision in a case that involves aspects of medical care or anatomy, physiology, pathophysiology, and microbiology—let alone sit back quietly listening to “lay people” try and hash through the details we simply “know more about.” For this reason the safe, ethically sound thing to do is to step back and away from any situation that puts you in the position of violating the tenets of professionalism that we took an oath to uphold and abide by.

     The take home message: Don’t toss out that text titled “Guide to the Code of Ethics for Nurses” once you graduate from nursing school…and if you did, you’ve most likely forgotten the very basic concepts of Ethics and should hop on to Amazon and purchase it here, along with another book like this. It’s never too late to grab a copy and keep it handy at work, in the car, at home….wherever there is a chance that what you do or say could jeopardize your license. If you are in the social media loop you might as well keep it next to you –Everywhere. Just saying.

Resources

Ewing, C. (2013). Judicial Notebook: Professionals in the jury room. Retrieved April 20, 2013, from American Psychological Association: http://www.apa.org/monitor/julaug00/jn.aspx

Fowler, M. D. (2010). Guide to the Code of Ethics for Nurses: Interpretation and Application. Silver Spring, MA: Nursebooks.org.

Tammelleo, D. (2012, June 1). Nursing law case on point. Retrieved April 19, 2013, from The Free Library: http://www.thefreelibrary.com/Nursing law case on point.-a0301181772

Behind Closed Doors Case #11: Hospital could be held liable for nursing negligence in failing to use leg cuffs

Information: Tisdale. v. Toledo Hospital, 2012-Ohio M10 L-15-1005 (3/16/2012)-0H

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

  

     Just back from a much needed vacation in sunny St. Croix, you’re feeling rejuvenated and sporting a killer tan (pictures too) that envious coworkers have been buzzing about all morning. It’s your first shift of four, and  the return to work has been a bit of a transition, because after three weeks away you happen to arrive the week the hospital is “going live” with the dreaded switch from paper charting to a new technology called “Computer Order Entry.” This new system allows physicians to get rid of all the pesky paper “order sets” and perform the same functions within a software program instead. It also allows nursing staff to perform all charting functions. The charts have literally disappeared overnight leaving everyone feeling hesitant, frustrated, and irritable because everything about the work day is taking longer than it used to. Gone are the days when one could pick up a chart, check and notate orders, and slide it back into the rack. Staff iPhones are also being implemented in tandem with the new system to improve timely and efficient communication between members of the healthcare team. Lucky for you, this piece is easy– having an iPhone is just a way of life.

           You’ve just received a text message from the team lead nurse that two new patients are on their way upstairs. One of them is from the ER and the other from PACU. She gives you their names so that you can access their computerized charts and begin looking at the orders physicians have entered for each one. The ER patient’s chest pain observation orders are pretty routine and expected, but the Esophagectomy patient has a more extensive list of orders to be notated and completed. Jotting down a list as you scroll through the screen you notate them all and breathe a sigh of relief that they have all been completed just as one of the patients is being rolled into a room. There is a sharp and reliable patient care assistant on staff today so you take him aside and notify him that the next patient coming upstairs—the lung surgery patient—will require sequential compression devices (SCD’s) and TED hose to be applied. He makes a quick note for himself at his desk and tells you he will take care of it.

      Your Esophagectomy patient arrives and an initial nursing assessment reveals several areas that give you concern. His name is Mr. Reyes. He is elderly, Spanish speaking only,  has a history for DVT, PE, uncontrolled Diabetes Mellitus, chronic wound issues, and is being maintained on Coumadin therapy. As you help the PACU nurses get the patient settled in you remind the patient care assistant about the urgent need for SCD’s. He nods in agreement and disappears after placing the patient on telemetry and obtaining an initial set of vital signs. The remainder of the shift is uneventful and it is soon time to go home.

      Day two of your “four day tour of duty” seems a little bit easier because you have the same group of patients back and have had a chance to become more familiar and secure with the new system. At about 1400 hours a patient care assistant approaches the desk to inform you that Mr. Reyes is feeling “suddenly short of breath” and his skin color doesn’t look good. The patient care assistant obtained an oxygen saturation reading of 87%  (on four liters of oxygen via nasal cannula).  Entering the room you quickly assess that Mr. Reyes is in acute distress—he is gripping the side rails of the bed and his lips are now turning a dark dusky color. You immediately direct the patient care assistant to raise the head of the bed to 45 degrees while you reach for the non- re-breather face mask, hook up the tubing, crank up the oxygen to 15 lpm and place it on Mr. Reyes’ face. He slumps forward, going unconscious. Without further hesitation, you flip open the cover to the Code Blue button, slam the palm of your hand against it, and call for help.

    Standing in the corner of his room, you watch as the code team works on Mr. Reyes. Your heart sinks as you realize 50 minutes has gone by without any signs of life. He is declared dead at 1540 hours. A day later you and your nurse manager are invited into an M & M conference to discuss the events leading up to the death of Mr. Reyes. All attendants are informed that the family has brought suit against the hospital and everyone involved in Mr. Reyes’ care.  The first three questions asked of you as the nurse are: 1.) Did you know that Mr. Reyes had SCD’s ordered for his lower extremities? 2.) Why were the TED Hose and SCD’s not applied to Mr. Reyes’ lower extremities as ordered by the surgical team? 3.) Were you aware that Mr. Reyes had a critical sub therapeutic INR lab result that morning?  In addition to these questions is one from your nurse manager: “Why was there no care plan entered into the computer for this patient?”

      You’d like nothing more than to provide the medical team the answers they are seeking, and to explain to your manager that you had planned to get help for the care plan part of the system since you’d be on shift for another two days…..Now, you are seated at the far end of a long table in a cold conference room with white coats lining each side…All eyes are on you….Waiting. 

 The Real Thing

  In August of 2002, Gary Tisdale underwent an abdominal surgery to repair a draining hernia at Toledo Hospital in Ohio.  Included in the post- operative orders was an order for “external pressure leg cuffs” to be applied to Gary’s legs as a means of DVT prophylaxis.  The cuffs were never applied by the nursing staff and Gary suffered a DVT that ultimately became a Pulmonary Embolism.  He required emergency surgery to remove the clots from his lungs, but sustained permanent blindness and brain damage from the incident.  Both Gary Tisdale and his wife Tammy brought suit against the hospital, the physicians, and nurses for medical malpractice, medical negligence, and loss of consortium.

 Questions for Consideration

1.   Identify some key points throughout the continuum of care when an order for SCD’s can get missed
2.   Would a nursing care plan have made a difference in whether the SCD’s made it to the patient or not?
3.   Pretend that that Mr. Tisdale was your patient. Apply the concept of critical thinking to how you would provide best care in this scenario
4.   Should devices like these be applied at the point they are ordered (in the unit they are ordered) or should it be the duty of the receiving unit to apply them to the patient? (i.e.: a patient going from surgery to a general medical surgical floor) Why or why not?
5.  Should the application or removal of SCD’s be a task that is delegated to unlicensed personnel, why or why not?
6.  Would teaching the patient prior to surgery about the need for SCD’s postop have made a potential difference?
7.  Should the patient’s advocate or family member be taught how to remove or apply these devices?
8.  How might the involvement of the patient’s wife or the patient’s health advocate prevented the adverse outcomes in this case?

 Discussion

      Hi- Touch, Hi- Tech, Hi- Thinking. Nothing can replace a careful, balanced approach to patient care as a means of assuring safe quality healthcare. Unfortunately, the current patient care environments we nurses practice in are set up to encourage anything *but* balance or nurse satisfaction—a surefire recipe for medical/nursing care errors to take place.   “A cross-sectional study of more than 95,000 nurses finds that direct care nurses in hospitals and nursing homes, who are often considered the first line of defense in patient care, are significantly more likely to be dissatisfied with their jobs (24% and 27% in hospitals and nursing homes, respectively) and to describe themselves as burned out (34% and 37%, respectively) than nurses in non -nursing jobs or jobs not involving direct care (of whom13% are dissatisfied and 22%burned out).” (McHugh MD, 2011) Today, nurses are being told to do MORE with LESS and do MORE with….MORE. I know it sounds confusing but read that sentence again—it really does make sense. We are expected to do more with less time and resources….while at the same time, accomplish more with all the Hi -Tech resources at our fingertips. What results from this combination is nothing short of disappointment when it comes to not only promoting– but preserving– consistently good patient care outcomes.  We as healthcare providers are forgetting, all too easily, about the basics…and it shows.  

      Effective communication, care planning, and collaborative practice among members of the healthcare team are vital components in any strategy to decrease sentinel events. “Weiss and Davis (1985) defined collaborative practice as ‘the interactions between nurse and physician that enable the knowledge and skills of both professions to synergistically influence the patient care provided.” (Nelson, 2008) When was the last time you did something that required “nurse think” (not tasks) – like updating a care plan or actually creating and implementing a care plan for a patient? Have you ever thought about your own favorite nursing theory and applied it to your daily nursing activities? These are conscious choices we make (to do or not to do)  every day we hit the floor running at 0700 or 1900, the shift mentally planned out– pushing hard to get the assessments done, the meds pushed out, and the charting completed. It’s here where the devil is lost in the details (errors), nursing morphs into something other than what it was meant to be, critical thinking  and care planning fall to the wayside, and patients become the recipients (and victims) of less than standard care.

       For the sake of this study, let’s assume there was no Nursing Care Plan in place for Mr. Tisdale during the hospitalization in question. How might a care plan have helped him to experience a better outcome? I’ve read the arguments for and against their use, and to be quite frank, I believe in nursing care plans 100%. They keep us efficient, effective, accountable, and they help other members of the healthcare team appreciate the fact that we aren’t just mindless drones going about our day completing one task after another like factory workers attending to products on a conveyor belt.  The more we allow newer technologies and an industry focused on speed and revenue to perform functions “for us” (i.e.: medication scanners, computer ordering, pre- filled charting) the less visible we become in the eyes of our medical colleagues, healthcare consumers, and each other. We as a profession become less of an Art, less of a Science, and have even less of an impact on patient care outcomes.  Computers, computerized order protocols, pre- made care plans, and other such technologies may be time savers but they cannot perform the critical thinking nurses can:  “The universal standards of clarity, accuracy, precision, relevance, depth, breadth, and logic are applied to check the quality of reasoning about a problem, issue, or patient situation—to think critically means that the nurse has control of these standards.” (Huckabay, 2009)

     We’ve all The Nursing Process drilled into our heads throughout nursing school. Unfortunately–many of us simply decided to leave it back on some random desk in the lecture hall hidden inside used textbooks and old care plans– never to be pondered again. (or at least said out loud around others) So, for those of you who need it–  here’s a review: Assessment, Diagnoses, Planning, Intervention, and Evaluation—Weaved within the circular sequence of steps that make up the process is an automatic dose of the “Hi Touch and Hi Thinking” approach to care I aspire to. Applied to Mr. Tisdale’s case, the use of the Nursing Process in devising the simplest post- surgical care plan may have kept those SCD’s front and center to the nurses’ thoughts and might have advanced the task of applying them higher up on his/her “nursey do list.” Newsflash here: messing up the big ticket items like medications, infusions, blood transfusions,  or hemodynamic monitoring pieces aren’t usually the mistakes that land nurses in the courtroom—it’s the details we program ourselves to think aren’t all that crucial (like care plans or TED hose),  or the “miscellaneous” orders that  “can wait for later.” Unfortunately for Mr. Tisdale, massive Pulmonary Emboli and a Stroke came before getting those SCD’s on “later.”

      I know all the arguments: “The machine isn’t here yet, the aide said he would take care of it for us, we have to call downstairs to get the right sized leg cuffs, the stock room is out but we will have more tomorrow, there are more important things to get done first, night shift can do it, day shift has a better chance of getting it done because they have more people working during the day….” I have been guilty of making one or more of those statements myself on really busy days. Regardless of our decision to act or not to act on behalf of a patient—the responsibility for what happens to him or her still lies in our hands as well as the tasks we delegate to others.  If you are the receiving nurse of a new patient, you are responsible for ensuring that orders are notated, delegated, followed up on and completed in a timely manner. Can’t get it all done? Fine. You are also obligated to properly hand off care and document a thorough nursing note at the end of your shift illustrating the course of events– including nursing care tasks you passed on to the next shift’s nurse.  *Always chart with a jury in the back of your mind* Now– ask yourself when signing off of a shift—are you confident that if called into a courtroom for deposition you’d be able to answer questions that justified the standard of care you provided to each one of the patients? “Nurses need to remember that the nursing process must guide all documentation. When courts examine records to see whether standards of care have been met they look for evidence of assessment, problem and risk recognition, planning, safe implementation, and evaluation of patient progress.” (Alfaro-LeFevre, 2012)

     Preceptors who reassure you that “no one does the care plans these days” or that they are “a waste of time” aren’t giving you permission to ignore that step in patient care: “Skip the principles of assessment and diagnosis and it’s easy to jump to conclusions, miss risks, and give care based on assumptions rather than evidence. Assessment errors and omissions are a major cause of adverse outcomes. If you fail to plan before implementation the risk of adverse outcomes also increases. Skip evaluation and reflective nursing practice (not to mention patient safety) goes out the door. ” (Alfaro-Lefevre, 2012) Proceed with caution. The sweet sense of security whispering in your ear that a sentinel event “will never happen to you” is dangerous. Tempting fate by omitting, failing to review, or update patient care plans is a mighty big gamble to take with any patient’s life and your license. It’s what attorneys look for, hone in on, and drill you on the stand about: “What justifies you having done A, B, or C with this patient?” “What justifies you not having provided A, B, or C for this patient?”

 ***Here is a bit of “Defensive Corporate Nursing 101”:  Never make the mistake of assuming your hospital will step up to defend you when a case goes bad and ends up in court. The responsibility for your license and your career is yours alone.***

 

 That being said– regularly engaging the use of the Nursing Process to create, implement  and maintain an individualized complete and updated nursing care plan for each patient under your care will be center to any good defense when a sentinel event has occurred.  Their use speaks volumes about your attention to detail, dedication to your craft, your integrity, and your professionalism—Simply put: Keeping them at the center of your daily practice activities can save your patient’s life, your life…and your future.

 

Resources

Hospital could be held liable for nursing negligence in failing to use leg cuffs. (2012, March 1). Retrieved from The Free Library: http://www.thefreelibrary.com/Hospital could be held liable for nursing negligence in failing to…-a0287112846

Alfaro-Lefevre, R. (2012). Nursing Process and Clinical Reasoning. Nursing Education Perspectives, 33(1).

Huckabay, L. (2009). Clinical Reasoned Judgement and the Nursing Process. Nursing Forum, 44(2), 72-78. Retrieved April 15, 2013

McHugh MD, e. a. (2011, May). Nurses’ Job Satisfaction Linked to Patient Satisfaction. American Journal of Nursing , 111(5). Retrieved April 15, 2013

Nelson, G. K. (2008, February). Nurse-Physician Collaboration On Medical- Surgical Units. MEDSURG Nursing, 17(1), 35-40. Retrieved April 15, 2013

Behind Closed Doors #10: Child who died in ER ordered to “leave” many times

   Information: Boone v. William W. Backus Hospital, 102 Conn. App. 305 (2007)–CT

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.

      Wintertime has arrived and this means that the Triage area of the Emergency Room has taken on the appearance of a war zone. Wadded up balls of Kleenex decorate the lobby, People are lying on the floor in hallways, snoring in chairs, and exhausted mothers are pacing the hallways trying to soothe crying babies. Of course, what would a winter night in Triage be without the two or three lovely souls who perch right in front of your window so that they are not easily forgotten? A peak outside your window reveals an ambulance bay that looks more like a circus. Fire trucks and police cars squeeze in where they can. There are bright lights, sirens, the sounds of doors slamming, the thud of Stryker stretchers being unloaded and reloaded hasn’t ceased since your arrival at 1900. This is one of those nights that will go down in history should you and your coworkers survive it. There have already been four codes (3 of which were walk-ins) and two deliveries in the elevator on the way up to labor and delivery (also walk-ins). Your heart sympathizes with the two sets of shocked parents who just became parents of pregnant teenage daughters who are now teen mothers in less than an hour.

     …0300 arrives and it’s “Autopilot time.” The never ending revolving door of sick children and tired, worried mothers has you exhausted. Neither you nor your coworkers have had the luxury of five minutes to eat or escape to the confines and quiet of a bathroom. About 0330 a familiar face arrives at your desk *AGAIN* with her 3 year old son. Except this time, he is not crying or fussing…he is lying limp in her arms pale and non- responsive. A quick assessment reveals he pulseless and apneic. You call a pediatric code overhead, place the toddler on the nearest stretcher and begin CPR. Your triage tech places a small bag valve mask over the boy’s face and sets to work trying to manage the airway. The whole waiting room of people is silenced, watching everything unfold….it seems like eternity before your ER code team bursts out of the double doors and takes over. You’re left standing there watching helplessly as the stretcher is rushed back behind the double doors. The horrified shrieks and cries of the mother surround you, causing the hairs on the back of your neck to stand up. There is a waiting room filled with patients still waiting to be seen and right now they are all looking at you in silence. Feeling overexposed you duck back into the triage office to try and process everything that has just occurred.

     The young boy’s name is Matthew. You remember him well because of his overly protective mother who is in and out of the ER at least two or three times a week to have her son evaluated for something or other. She is a single mother, Spanish speaking only, and has no insurance for herself or her son because they do not qualify for government benefits. Today Matthew was in your triage office several times throughout the day because of a persistent ear infection. He was seen by the ER Physician early this morning and given an injection of antibiotics. Your knowledge of the Spanish language is pretty limited, but what you do make out is that her son got very ill after the shot and his symptoms have all been GI related.  You figured he was developing the flu or experiencing nausea from both the antibiotic injection and the ear pain. Trying to save her the expense of any more bills you repeatedly reassured the mother, advising her to go home and put Matthew to bed with some cool compresses to his forehead.

An hour after Matthew’s lifeless body was rushed back to one of the major rooms one of your colleagues emerges from the double doors and you know it isn’t good news because she is openly sobbing as she makes her way outside the ER sliding doors for some air. She barely makes it out the sliding doors before throwing up on the sidewalk. Your heart sinks and you begin to feel lightheaded and weak on your feet. There is only about an hour left on the shift and you call your nurse manager, requesting someone relieve you in triage due to the event that has occurred. You need time to decompress. Heading back through the double doors you cover up with an extra sweater hoping it will protect you from the chill your body feels from the inside out. Looking back on the shift you are recounting the many opportunities there were to push this case in front of one of the ER doctors, to advocate, to do….something….But you were tired, agitated, and annoyed by a mother who you had mentally labeled a “frequent flyer,” an “annoyance,” “overly protective and paranoid.” No, you never uttered the words—but you paid less attention to Matthew, his symptoms, the signs that could have….should have…alerted you to danger.

As you push through the door of the break room a wave of nausea and dizziness takes over. Your colleagues at the table look farther away…. their voices more distant….until everything goes black……

The Real Thing

 On December 22, 1999 at 1730 hours, four year old Kyle Boone was brought to Connecticut’s William W. Backus Hospital by his mother Heidi Hansen. He had right sided ear pain and purulent discharge coming from the same side. Kyle was treated, received medication, but became very ill shortly thereafter. The emergency room nurse who was assigned to care for both Kyle and his mother reassured Heidi that “his reaction to the medication was ‘normal’ and that it was safe to take him home.” (Tammelleo, 2007) After being discharged from W.W. Backus Emergency Room, Kyle’s condition continued to get worse throughout the day and night. Desperate for help, Heidi brought her son to the same emergency room several more times for treatment only to be told by staffers to “Leave.” During one of the mother’s attempts, staff had threatened to have security guards remove both mother and child off the hospital campus. On Heidi’s last attempt to get medical care for her son in the ER, Kyle’s condition had deteriorated. He was noted to be lethargic and unresponsive to providers. Attempts to revive the boy were futile and Kyle was pronounced dead. There is no mention of whether the care administered (or withheld) by the nurse or nurses involved in this case was investigated or whether any of the nurses were held responsible and disciplined as a result of the case against William W. Backus Hospital.

Questions for Consideration

1. Review Maslow’s Hierarchy of Needs and apply the theory to your experiences in the workplace or in nursing school. Are there parts of your pyramid missing? If so, which components?

1. Define the concept of justice and discuss its pertinence to the clinical case presented above (was it absent, and in what ways? Provide examples.)

1. Does the concept of justice have a place within Maslow’s Hierarchy of Needs? If so, why?

1. Think of both the mother and son as separate in the case and discuss the Maslow needs of each individual. Construct a care plan for each and compare/contrast your care plan with the Hierarchy. Do the two have any similarities? If so, discuss them.

1. Provide examples of how you as a student or nurse could easily incorporate Maslow into your daily caring activities.

6. Recall your preferred nursing theorist. Are there any similarities between their theory and Maslow’s Hierarchy? Does the theorist incorporate concepts similar to Maslow’s Hierarchy of Needs into their theory? If so, how?

Discussion

      I get it. I really do. I did some time in the Emergency Room as a patient care technician numerous years ago. I was in the trenches with the nurses doing all the down and dirty stuff with them, and I experienced pretty much everything they did. Frequently overwhelmed by stress, I fell victim to fatigue, impatience, hunger, and the primal urge to go running and screaming out those ambulance doors the moment 0730 hours arrived. I was also relentlessly bullied by my nursing supervisor Betty for the duration of those years. (In fact, I still make sure she isn’t on shift when I have to take my daughter to the ER for asthma exacerbations) My memories of her are very vivid. She would yell at me, berate me, curse at me and insult me in front of everyone—including the patients. I was too afraid to stand up and defend myself, which made the Emergency Room an even more burdensome, unsafe place to exist.  The point is, there are *many* factors that contribute to the type of care we give other human beings, especially when our own basic needs are threatened and going unfulfilled for long periods of time. It’s hard to give others what we lack ourselves, but as healthcare providers we are obligated to ensure our patients receive the best care possible—every time.

It seems like the bigger and busier an Emergency Room is the quicker your emotional and physical batteries are drained, especially during those dreaded winter shifts when it feels like the needs of everyone else in the world take precedence over the very act of you breathing. Understandably, it can be easy to forget some very simple things: Patients don’t appear out of nowhere to make our lives more stressful or miserable, they don’t have the magical ability to understand what is happening to them or their family members…and contrary to popular belief, the LAST thing patients want to do is isolate themselves from HELP by pissing us off or getting on our bad side in some way or another. (HINT: There is a very good reason patients try and joke with us…they want to feel a kinship with us in order to fulfill the need for belonging.)

This case highlights some excellent opportunities to review and incorporate Maslow’s Hierarchy of Needs as a quick and easy mental reference tool for nurses to call upon when encountering clients of different ages who have varied developmental and psychosocial needs—or even when contemplating the needs of coworkers. If not doing so already, nurse managers would do well in implementing programs on their units that incorporate the Hierarchy as a means of improving productivity, morale, and team cohesiveness which all affect overall patient care outcomes: “If leaders, those that have the ability to influence the lives of workers, take into consideration the needs of the individual, the new technology that provides challenges and opportunities for meeting those needs, and provides the training to meet both sets of needs, enhanced employee motivation and commitment is possible. The Maslow model presents a means for understanding the needs of the individual and the worker; ever present and growing technology allows for new ways to meet these needs; and training makes the worker more secure, can enhance feelings of belongingness and self-esteem, and provides the opportunity for self-actualization.” (Benson, 2003) Its application to everyday practice is a simple, powerful, and cost effective means of improving the quality of care we give to any patient population.

Now, a brief review: The Hierarchy, as devised by psychology professor Abraham Maslow in 1943 posits that humans are motivated by five basic needs that guide their behaviors—whether it be participating in self- care activities or striving to reach goals in the workplace. The needs range from simple to complex and are framed within the shape of a pyramid: “Maslow created a visualization of his hypothesis in the shape of a pyramid which is divided into five levels. At the bottom of the pyramid is the physiological level which includes food, water, and shelter, the most basic needs for human survival. The premise is that unless an individual’s basic needs have been met, higher levels in the pyramid are of no relevance, as survival is the most basic human component.” (Benson, 2003) Every patient comes to us with one or more needs that need to be fulfilled and we as nurses have frequent critical opportunities to ensure those needs are met in virtually every healthcare setting. The opportunity can be as complex as mapping out a plan to improve the nutritional status of a patient or as simple as taking five minutes to educate your patient about the pain scale or their daily medications.

Frequent use of the call light, patients loudly calling out “Nuuuuurrrrrrrrrrrrrrrrse” every thirty seconds from their rooms, family members hovering over our workstations, patients refusing medications, and the beloved frequent flyers— we’ve all experienced those little joys throughout our careers.  As a nurse I have learned the hard way over the years that a patient or family member isn’t acting out toward me for the sake of his/her entertainment or from boredom, rather, there is always an underlying reason(s) for the things they say, do, or flat out refuse to do. To keep this in mind, I began carrying around a reminder card detailing “Maslow’s Needs” so that while I worked on the heart transplant unit I’d have a ready reminder of what approach to take when having difficulties with patients or coworkers. I now affectionately refer to these learning opportunities as “Maslow Moments.”

I selected this case for discussion because I worked in both the ER and floor settings.  I’ve experienced the unique challenges nurses face within each milieu, and I also know it’s easy to get caught up in thinking about the long list of things (our own physiological and emotional needs aside) that have to get done in 12 short hours — while at the same time– working in the unexpected stuff, like that patient who suddenly goes bad and needs to go to the ICU or a code blue that didn’t end so well. That being said, nothing justifies a failure to rescue. The mother in this case expressed concern to the nurse before leaving the Emergency Room with her son the first time around—consider that critical opportunity #1 for any nurse to STOP everything, SIT down, make eye contact and  LISTEN to what ISN’T being said out loud. Had the nurse caring for the mother and son exercised these basic steps he/she may not have made the judgment call advising the mother her son’s reaction to the medication was “normal” and that it was safe to take him home.  Perhaps the nurse would have assessed an ER Physician needed to come back in and take another look at the boy to make those decisions.

The mother’s subsequent returns to the Emergency Room were additional opportunities for nurses to STOP, SIT, make EYE CONTACT, and LISTEN for those unspoken needs. When applying Maslow’s Hierarchy of Needs to the above case it’s easy to identify that both she and her son possessed physiological, safety, belonging, and esteem needs that were far from being assessed or met. Sensing danger, the mother did not feel safe, she probably felt isolated in her attempts to secure medical care for her son whose own physiological needs were threatened, they were denied the shelter of a medical home, and the mother was demeaned as a parent when staff threatened to have both her and her son removed from the ER by security staffers.

No doubt, the facts related to the nursing care in the case above are disturbing to say the least. In all fairness, I recognize that we lack full disclosure to what the circumstances were that night– whether the ER was fully saturated , what kind of pressure the nurses were experiencing, whether the ER was short staffed, or whether the nurses were working longer shifts than normal. Those factors aside— what stands out to me are the repeated, desperate, and ultimately futile attempts of a mother to get medical assistance for her son and the opportunity nurses had to simply stop, take a cleansing breath, remember the nursing process, our role as advocates and protectors, our oath, our code of ethics…and to REASSESS the scene. It is, after all, part of the nursing process.

ASSESSMENT:  It’s what we are educated, licensed, and legally obligated to do for every patient every time….no matter the circumstance. No life should be left behind or sacrificed for the sake of our own comfort or relief…..Ever.   

Resources

Anthony Boone, Administrator v. The William W. Backus Hospital, CV010559435S (Superior Court of Connecticut September 26, 2003).

Benson, S. &. (2003). Understanding and motivating healthcare employees: integrating Maslow’s hierarchy of needs, training and technology. Journal of Nursing Management, 315-320. Retrieved April 5, 2013

Johnstone, M. (2010). Nursing and justice as a basic human need. Nursing Philosophy, 12, 34-44. Retrieved March 5, 2013

Nyden, K. P. (2003). Unsatisfied basic needs of older patients in emergency care environments–obstacles to an active role in decision making. Journal of Clinical Nursing, 12, 268-274. Retrieved April 5, 2013

Sadri, G. &. (2011). Meeting Employee Requirements. Industrial Engineer, 45-48. Retrieved April 5, 2013

Tammelleo, D. (2007, October 1). Child who died in ER ordered to “leave” many times. Retrieved April 5, 2013, from The Free Library: http://www.thefreelibrary.com/Child who died in ER ordered to “leave” many times.-a0170454202

Behind Closed Doors Case #9: SPECIAL EDITION

Information: The Estate of L. Bayless versus ?? (no current litigation exists)

Summary: Healthcare worker self identifying as a “Nurse” refuses to administer CPR citing “employer/facility policy”—resident dies

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe nursing practice. Thank You.

     You’ve spent the better part of a year trying to find a job as a new nurse. Compounding your efforts is the fact you are early into your first pregnancy. Exasperated, you decide to start applying out of state in hopes of broadening your prospects and are thrilled when a beautifully updated independent living facility (with three levels of care for residents)  offers you a job. Your husband, an electrical engineer who graduated from the local state university with you a year ago has been having a tough time finding a job as well— so he is more than happy to help pack up the apartment and hit the road. It seems that brighter days are ahead for both of you. Surely he will find a job in California. For now, you will be the breadwinner and will be able set aside some money in anticipation of the baby that is due in another six months.

     The first week in California is a whirlwind of activity. There are numerous orientation classes to attend at the facility, tours to take, management figures to meet, business at the State Board of Nursing to take care of (to ensure your license is secured in the new state you are living in), finding a new OBGYN, and of course setting up house in the small apartment you and your husband are relieved to have found on such short notice. It’s an old, tiny, run down studio…the perk? It’s located a little over half a block away from the beach. Your husband, an avid runner, has already declared the mornings as “his time” to run alongside the water.

     Your new nursing career officially begins the second week in California and the first day at the independent living facility is anything but exciting— in fact, it’s horrendously stressful. You feel absolutely clueless. The nurses are not helpful here other than to make it clear that YOU are in THEIR way. Every question is dumb. Every move or sound you make is a nuisance. Clearly you are on your own to figure out where your place is as part of the nursing staff of The Cliffside Coves. At 1700 hours you’re feeling kind of lightheaded and dizzy so you head over to the “always open” gourmet dining hall to get a snack. You are optimistic because in one more hour your first nursing shift will be complete and a peaceful, barefoot walk on the beach with your husband lies ahead.

Savory aromas are swirling all around you as residents come and go from the dining hall. As you browse through the take away cart counting calories, a call for help sounds out. A female resident has gone down and her male friend is pleading for help. You rush over, kneel down, and check for any sign of breathing or pulses—of which there are none. Making eye contact with the wait staff, you request that 911 be called immediately.  Performing a head tilt chin lift maneuver you prepare to administer CPR when a male hand reaches over to stop you. It’s one of the nursing managers on staff—he is advising you that CPR is not performed at this facility and it is their policy to do nothing more than call 911 and wait for help to arrive. The male friend informs you his partner has made it clear she wants CPR should she ever require it and is begging you to begin CPR….but your manager’s hand remains on top of yours…..as yours rest on top of the pulseless and apneic female resident’s chest. In just a matter of seconds you have to make the choice of a lifetime….a decision that will not only affect the life and future of a stranger… but yours, your husband’s, and your unborn baby’s as well.

The Real Thing

On February 26, 2013 at 1100 hours 87 year old Lorraine Bayless collapsed in the dining hall of Glenwood Gardens, a multilevel nursing care facility located in Bakersfield, California—she had been a resident of the independent living area of the campus. The fire department was summoned at 1107 hours and arrived at the facility at 1113. Members of the fire department were given paperwork for Bayless in which no DNR was found. They immediately began CPR and transported her to Mercy Southwest Hospital. She died shortly after arrival from what has now been identified as a massive stroke (per her death record). These basic facts are similar to those you would expect to unearth on just about any death that occurs at a nursing care facility or an independent living facility, but they aren’t what the eyes of the nation have been focused on these past couple of weeks—the concerns revolve around all the unknown variables in the mix and the 911 tape heard around the country…the contents of which have ignited a firestorm of questions healthcare consumers, bloggers, journalists, and the healthcare community at large are currently debating the answers to. A woman identifying herself as a nurse is heard repeatedly telling the dispatcher she cannot, per her employer’s policy—administer CPR to Ms. Bayless. The same woman refused to summon any passersby who were not on staff to render aid when the dispatcher begged her to do so.

 

      So…. who is right? Who is wrong? Well that depends on you, your beliefs, and whether you are a healthcare consumer or a healthcare provider. Embedded within the few minutes of the 911 tape is a complex and multifaceted set of issues that must be addressed in order to: A.) Restore some trust between healthcare consumers and healthcare providers who work at these kinds of facilities, B.) Ensure that the rights and wishes of every human being are preserved, and  C.) Remind both nurses and other healthcare providers of why  knowledge of basic ethical principles and their application to everyday practice is so very crucial to providing best care to every human, every time, no matter WHERE they require our help.

QUESTIONS FOR CONSIDERATION:

1. Would you have administered CPR? Why or Why Not?

1. As a nurse do you think it is okay to accept a job in which you know you will not be allowed to render aid in similar circumstances?  Why or why not?

1. Would you as a nurse have tried to protect your job before acting on behalf of your patient in a similar circumstance? Why or why not?

1. How would your personal values and beliefs impact your actions in similar circumstances?

1. Apply basic ethical principles to the case discussed above—do you believe the application of ethics was missing? If so, give examples of how.

1. Provide some examples of how the case above conflicts with the oath we take as nurses, the Code of Ethics for Nurses, the American Nurses Association Standard of Nursing Care or your own state’s Nurse Practice Act

1. Before looking it up–What does moral courage mean to you? How would you display moral courage and under what circumstances?

1. Is moral courage required to be a good nurse? Why or why not?

Discussion

 I have no doubt that there exists hundreds upon hundreds of media responses to the Glenwood Gardens incident in the form of  opinions, discussions, debates, columns, blogs, articles, and interviews. It raises many concerns, –and rightfully so. I’m going to take a hypothetical approach and say that it was indeed a Registered Nurse who refused to render aid. Now, recall the oath we take upon graduation and that we are bound to behave according to the Code of Ethics for Nurses while engaged in the business of caring. This case should cause one to pause and query whether the world of academia has prepared today’s nurses aggressively and effectively enough to understand, practice, and apply basic ethical precepts to everyday work. Moreover, do nurses understand that acting in an ethically sound manner is not a casual choice, rather, an expectation? Lastly, are the glossy buzzwords  “moral courage” simply things to be tossed about in articles, textbooks, and blogs or do nurses truly not “get” (beyond the walls of academia) that we are obligated to act in such a way that places the interests of another human being ahead of our own well- being?

 

    Nurses go to school for years, some stacking up as many years of training as doctors do.  We make sacrifices. We dream of that seemingly elusive “last care plan” or “last clinical rotation” signaling that graduation is around the corner. Our families make huge concessions so that we can finish our nursing programs. Our own health, at times, takes some pretty big hits on the journey toward achieving the RN credentials after our names. Compounding the challenges of newly minted nurses are the recent hiring trends that seem to shut out inexperienced RN’s from the industry by only considering “experienced nurses” for employment opportunities. No doubt, the real world comes calling quick just moments after a nursing student walks down that long aisle to receive his/her diploma. After all, bills still need to be paid… and before long the feds come calling for financial aid loan payments. Any nursing job opportunity becomes a highly sought after commodity in the eyes of new nurses, and for this reason I’d like to implore readers to stop and think twice before snatching the first opportunity that comes along. Ask yourself—is it okay to take a job in which you know you will not be allowed to do the very things a nurse practice act says you can do, that are within your licensure to do, and that are mandated of you by oath and by the Code of Ethics for Nurses?

     The Glenwood Gardens incident highlights some very important reasons why nurses seeking employment in the healthcare industry should research any potential place of employment and ensure that “it” is a good fit for the “nurse,” and not the other way around. Dr. Phil has a saying that I find rings true in many areas of life and I think it fits well with nurses and the healthcare industry: “We teach the world how to treat us.” Applied to nurses—we teach both the industry and coworkers how to treat us or value us, what we will tolerate and accept in the workplace, and how serious we are about the oath we take and abiding by strong moral and ethical standards in the day to day care of patients. Simply put: when we “settle” for “what we can get” for the sake of getting employment as a nurse, we may be sending a dangerous message to the healthcare industry that says “you can redefine my profession as you wish, you can decide whether my work environment will be safe or not, you can decide whether I have the resources I need to do my job or not, you can decide whether my oath or code of ethics means anything within your organization.”  If we start at the beginning—one new nurse at a time, change can happen and organizations will begin to see that we as a profession mean business when it comes to upholding our oath and standards of practice in the workplace.

     There are two more concerns that resonate within me when I listen to the 911 tape (listen to it here): First, the woman who identified herself as a nurse,  and second– the voice of “management” in the background instructing the supposed nurse to standby and wait for paramedics to arrive despite the pleas of the dispatcher to find a passerby who could administer CPR to Ms. Bayless. They represent two opportunities for nursing, as a profession, to act. (Recall that this incident quickly made headlines on the Today Show and Good Morning America) We are often touted as among the most trusted individuals in the healthcare industry. When someone intentionally deceives others by identifying him/herself as a nursing professional in a very public situation like this I believe we have a duty to thoroughly investigate and ensure appropriate legal action is taken in whatever state the deception occurs. This unfortunate incident has the potential to undermine the public’s trust in Nursing as a profession because the individual identifying themselves as a nurse is on record as refusing to render lifesaving CPR to someone who needs it because her employer said not to.

 

     Now, a word or two on what nurses can be doing at both the state and federal levels to ensure that our practice is not further infringed upon by private or corporate entities and that healthcare consumers can trust we do view their rights and best interests as a priority..Yes, I’m about to say the “P Word”:  Politics.  It isn’t easy—it can be exhilarating, frustrating, time consuming, disappointing and rewarding all at once….it takes time, passion, and a certain kind of dedication to keep moving forward with efforts to make changes that benefit your fellow man. Who else better to do it than nurses? In my state of Arizona there is not a single nurse currently serving in the state legislature. I wonder whether any facility would dare set forth a policy that does not allow a Registered Nurse to render life- saving aid to a nursing facility resident if there was a Registered Nurse serving in their respective state’s legislature….

     As a profession we have no business bitching and whining about how Nursing looks when a tragedy like Glenwood occurs– social media arm chair quarterbacking behind anonymous postings, critiquing or arguing with others, appearing appalled while asking how facilities could “dare” to set forth policies prohibiting “US” from adhering to “OUR” oath and code when members of our profession aren’t out there at the highest level of politics (The White House and Congress) putting their foot down saying “this isn’t how it’s going to be– not now, not ever, because I’m here representing nurses and patients to tell you how it “is going to be.”  Right now, we as a profession allow it all to happen because people are too afraid to speak out and rise together for change. God forbid one of us stands up, raises his/her voice, and loses carefully constructed personas, reputations, and looks bad to everyone else. Well, here’s a question– 20 years from now if you are still a nurse what will be the most important thing you will have done to leave the profession of Nursing a better place for the next generation…. The play it safe strategy?  Your silence?  Your fear?  Your popularity at work? This incident should make us all stop and ask ourselves what we can be doing better — not just as individual practitioners but as a whole. 

 

When something like the Glenwood incident happens again—and rest assured it will—  be content to be part of the problem or get to work creating solutions that ensure not one more healthcare facility will be allowed to silently and passively enforce a policy telling its employees (and that includes its nurses) that the “rules” come before what is “right.”

Think about it…..Hindsight’s 20/20, we know not who all was standing by watching Lorraine Bayless slip away that day….

“Non- Scholarly” Sources:

http://www.bakersfieldcalifornian.com/local/x738926924/Police-probe-Glenwood-Gardens-death

http://www.bakersfieldcalifornian.com/health/x837006603/Document-Do-not-resuscitate-order-was-not-on-hand-for-Glenwood-Gardens-resident

http://www.bakersfieldcalifornian.com/local/x738926892/Glenwood-Gardens-visitors-withhold-judgment-on-nurses-refusal-to-provide-CPR

http://www.bakersfieldcalifornian.com/health/x837006530/911-recording-details-dispatchers-struggle-to-get-aid-for-elderly-woman

http://www.bakersfieldcalifornian.com/archive/x921547996/file?nodisp=1

Behind Closed Doors Case #8

Information: Aragon v. Issa, 4D10-3993 (FLCA4) (10/17/2012)-FL

Summary: Failure to notify Dr. of positive test for allergy: death resulted

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe nursing practice. Thank You.

(Published with permission from nursefriendly.com)

 

 

     Today is your birthday and you’ve been counting down the hours and minutes until the end of shift. It’s your third in a row, five luxurious days off lie ahead, and a beautiful silver stretch Hummer is parked downstairs in the main parking lot waiting just for you! Your best friends are also in that Hummer with gifts, a new dress, stilettos, and makeup you purchased the last week in anticipation of this night. Sighing impatiently you let the window blinds fall back into place, check your watch for the thousandth time, and walk out of the empty patient room and back out to the nursing station. The new patient should have arrived over an hour ago from the ER… “As usual” you mutter. It’s going to be another stupid shift change admission you’ll have to trip through as you try to give report while hurriedly securing him/her into a hospital bed with both telemetry and a call light. You’re hoping there are no family members to complicate the transition with a bunch of weird requests and questions—and you’ve already decided that you’re sticking to the basics: Airway, Breathing, Circulation. It’s shift change and vital signs are all the night shift nurse is going to get, along with a brief description of why the patient is there. After all, the patient is arriving on “their time” and you have done enough in one day—it’s time to go blow off some steam and get on with your night!

     Leo Nessi, a 56 year old male, arrives as predicted—at 1905 hours. You take report from the ER nurse who has been so nicely caring (or sand bagging) for the patient since the orders to transfer to the telemetry floor were transcribed four hours ago. Tired, annoyed, and in a hurry, you jot down what meds Leo has had downstairs, his most current heart rhythm, and that he is there for chest pain that subsided with oxygen and bed-rest in the ER. He has had two negative Troponin levels and a third level should have been resulted about 30 minutes ago but the nurse hasn’t had time to look it up. You ask her about any patient allergies and she is unsure but says the electronic medical record has been flagged “for something.” The nurse puts up a hand to signal a goodbye after loading up the cart with the defibrillator and linens and rushes out of the room. Leo is by himself; he is alert and oriented to person, place, time and situation. He has a normal sinus rhythm in the 60’s. His respirations are 18 per minute– even and unlabored. He is afebrile and pain free. Smiling you inform Leo he looks like perfection and reassure him that the night nurse will be in as soon as shift change report is over. He is quite obese so you inquire as to whether he ambulates around at home without a problem and Leo assures you he “gets around just fine!” He sounds a bit testy so you bid Leo farewell after handing him the call light with instructions to call for any assistance he may need. He grunts something about how he is supposed to find ESPN but there is no time for such a discussion….so you take your leave and rush out to the nurse’s station to end your day.

     While pausing at your desk, you look up Leo’s electronic medical record to review the latest Troponin level and what Allergy(s) he has. Your iPhone begins ringing. The girls want to know what’s taking so long. There are 12 of them in the Hummer downstairs. Their peals of laughter and the clinking of glasses as they toast can be heard in the background… music is playing.  While updating your best friend a fresh wave of impatience washes over you because you’re still stuck on the unit waiting to give report.

     The night nurse finally makes her way over to your desk and report is wrapped up in record time. Your iPhone rings again while you’re in the elevator and as you pull it out of your scrub coat there is a stickie note attached to it—it’s Leo’s Allergy to Shellfish and his latest Troponin level—it’s quite elevated. You wonder whether you should go back upstairs and alert the night nurse…but the elevator doors open and you are immediately mobbed by your best friends who are rushing you into the first floor ladies room to help you change, touch up your hair, and apply your makeup….it’s Friday night, it’s your birthday, and it’s time to breathe!

     Two days into your five day vacation away from the hospital you receive a phone message from the unit nursing manager. She has some questions about Leo’s assessment and the shift change report you were a part of a couple of evenings ago. A sick feeling grips your stomach when you call back and learn that Leo died in the cath-lab as a result of a heart attack and an allergic response to the dye used in the procedure. The doctors were upset that Leo’s elevated Troponins and list of allergies (which included shellfish) were never reported to them by nursing staff. He was rushed to the cath-lab the next morning due to an acute chest pain event during which he became unstable. Leo quickly coded when the dye was introduced and the team was unable to revive him. The family is now bringing suit against everyone involved in Leo’s care.

     After a meeting has been set up with the nursing manager for the next morning you hang up and reach over to one of the dining room chairs to sit down. Flashes of nursing school graduation four months ago appear in your mind’s eye. You just got a new sports car, a new house, new furniture…. and with one phone call it suddenly feels as if everything is falling down around you.

The Real Thing

         At 1150 hours on November 7^th of 2004, 41 year old Leo Aragon was admitted to the Emergency Room at Memorial Regional Hospital with symptoms suggestive of acute coronary syndrome (ACS). His chief complaints were as follows: Left arm and left sided chest pain that radiated to his neck and back, shortness of breath, nausea, and increased blood pressure. He was noted to be quite obese and an allergy to shellfish was recorded on the medical record. While in the Emergency Room Leo’s EKG and cardiac enzyme tests returned normal. Creatine Kinase (CK), Creating Kinase-Myocardial Band (CK-MB)-, and Troponin are the three tests performed in virtually every Emergency Room and/or Chest Pain Center to rule out a heart attack. These enzymes are leaked out into the bloodstream as the myocytes sustain damage and become necrotic. The levels often rise over time, hence the need for serial testing. “As an acute MI progresses, myocytes become necrotic, resulting in the extrusion of their intracellular components into serum. With each cardiac enzyme and marker, the time differential from the onset of an acute MI to detection in serum varies, depending on the size of the molecules and the degree of perfusion in the infarcted area. CK is typically detected 4 to 6 hours after the onset of infarction, with serum levels peaking at 24 hours and returning to normal after 3 to 4 days. The troponins first become detectable in serum after the first few hours following the onset of myocardial necrosis, and they peak after 12 to 24 hours. [6,7] Normalization of cTnT levels requires 5 to 14 days; cTnI requires 5 to 10 days.”(Berry, 2000)   More evidence based information about the guidelines for Acute Coronary Syndrome is available at the The Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse.

     After speaking with Leo’s Primary Care providers the Emergency Room physician admitted Leo for observation to ensure that serial results didn’t return positive.  The initial troponin level had been ordered at 1200, so the admitting service ordered two more levels to be drawn at eight hour intervals. The actual draw times occurred at 2130 and 0455 the following morning. The 2130 result returned as positive but the nursing staff did not inform the physician service until the second positive result came back at 0720. Interestingly, the physicians involved in Leo’s care had already planned on performing a heart catheterization prior to receiving any of the two positive enzyme results. Leo would later suffer an anaphylactic reaction and die as a result of the dye used in the procedure.  A lawsuit was brought against Memorial Regional Hospital and all the physicians involved in Leo’s care. None of the nurses who cared for Leo were included in the suit.  The court decided in favor of Leo Aragon’s estate, finding all the defendants liable for Leo’s death.

A word or two about patients who have an allergy to shellfish: A recent literature review reveals that individuals who are atopic have a higher risk for experiencing a reaction to IV contrast dye such as the one discussed in this case. Now, don’t get the words “atopic and allergy” confused.  “Atopy” is about genetics:  “Atopy is the genetic predisposition of an individual to produce high quantities of IgE in response to allergens in the environment (pollens, house dust mites, molds, cat dander, foods etc). Heredity is very important in atopy i.e., you inherit this predisposition to produce IgE from your mother, your father, or both. Thus, atopy represents the background for sensitization: only atopic people (those with genetic predisposition) develop sensitization to one or more allergens.” (UCB Institute of Allergy, 2011) An Allergy occurs when an individual comes into contact with the substances a person is sensitive to.

Perhaps taking a second look at any patient with a history for anaphylaxis or severe asthma would be prudent? “The risk of reactions to contrast ranges from 0.2-17%, depending on the type of contrast used, the severity of reaction considered, and the prior history of any allergy. The risk of reaction in patients with a seafood allergy is similar to that in patients with other food allergies or asthma. A history of prior reaction to contrast increases the risk of mild reactions to as high as 7-17%, but has not been shown to increase the rate of severe reactions. Severe reactions occur in 0.02-0.5% and deaths in 0.0006-0.006%; neither have been related to “iodine allergy,” seafood allergy, or prior contrast reaction… Allergies to shellfish, in particular, do not increase the risk of reaction to intravenous contrast any more that of other allergies.” (Schabelman, 2010)

 

Questions for Consideration:

1. Should the ER nurse, the day shift nurse, and the night shift nurse have been included in the lawsuit? If so, on what grounds?
2. Can you identify some common distractions that could have potentially put you and this patient in the same kind of scenario? Were there any identifiable gaps in care?
3. The method of reporting was not mentioned in the public document. What kind of impact would nurse-physician rounding have had here? Discuss thoughts on an Interdisciplinary Model of Care and Bedside Report  at shift change, or the transfer of care between units at “safe times” as a means to improve safety for both the nurse and patient.
4. If the nursing staff knew that a heart catheterization had been planned for Mr. Aragon do you think it was their primary responsibility to both inform and caution the physicians involved about the allergy to shellfish or is this primarily the physician’s job?
5. Is it primarily the role of the physician to be checking for blood test results as in this case or should the nurse have been the “primary gatekeeper” overnight—overseeing and notifying the physician staff when required?
6. Have you ever stopped to consider how important the concept of Communication is in your daily work life or have you become disconnected from it?
7. Review the terms “sentinel event” and “never event.” Recalling the Centers for Medicare and Medicaid Services (CMS) sweeping changes for reimbursement to hospitals, what will these terms mean to you and how can they potentially affect your workplace?

Conclusion

     It’s my opinion that in the case of Mr. Aragon there were several areas in which communication fell to the wayside and a life was lost. The care of a patient is a shared experience, and the duty to protect falls on the shoulders of every person who comes into contact not just with the patient but anyone who logs into his/her medical record. There is no room for assumptions whether it is on a night shift or a dayshift or even where technology is concerned. Nowadays physicians and residents have instant remote access to the records and results for a patient making it that much easier for a nurse to assume Dr. Smith is “watching from home” or for Dr. Smith to assume the nurse will call and alert him/her of a dangerous lab result. Developing and honing safe practices are key to reminding yourself throughout the day what your responsibilities are in the care of patients—and it’s a great way to filter out the “but so and so does that” inner dialogue that can so easily creep in the more complex a case gets—or when even the most routine cases come across your desk.

     Communication. It seems like one of those minor run of the mill concepts that we tend to turn a deaf ear to– but, let’s assume (correctly) that the preservation of any life in our hands is priority one on the job…how much bigger does that concept become? Now, consider your hard earned nursing license and how easily such a routine concept like communication can make or break your livelihood. Mr. Aragon’s case is a sobering illustration of why healthcare providers from all disciplines must continue the push toward more effective, collegial, timely, and team oriented communication that firmly secures the patient at the center of their care.

The next time you are back on the unit evaluate how you can do it…*Better*…  Any of these nurses could have easily been you.

References:

Agency for Healthcare and Research Quality. (2010, April 30). (Wiley Interscience) Retrieved March 3, 2012, from National Guideline Clearinghouse: Acute Coronary Syndrome and MI: http://guideline.gov/content.aspx?id=33192

UCB Institute of Allergy. (2011, September 12). Retrieved March 3, 2013, from Atopy Versus Allergy: http://www.theucbinstituteofallergy.com/patient-and-public/What-is-Allergy/How-does-allergy-develop/Atopy-versus-allergy

The Free Library. (2012, November 1). Retrieved March 3, 2013, from Case On Point: Failure to notify Dr. of positive test for allergy: death resulted: http://www.thefreelibrary.com/Failure+to+notify+Dr.+of+positive+test+for+allergy%3a+death+resulted.-a0318345352

Berry, J. C. (2000). Using cardiac enzymes and markers in acute MI. Patient Care, 34(14), 12. Retrieved March 3, 2013 from the Phoenix Public Library

Florida Fourth District Court (2012). Aragon versus Issa: Court Opinion. Retrieved March 3, 2013, from http://www.4dca.org/opinions/Oct%202012/10-17-12/4D10-3993.op.pdf

Schabelman, E. &. (2010, November). PubMed.Gov. (U. N. Health, Producer) Retrieved March 3, 2013, from The relationship of radiocontrast, iodine, and seafood allergies: a medical myth exposed: http://www.ncbi.nlm.nih.gov/pubmed/20045605

For One Night He Turned Me Into The Homecoming Queen: Thank You.

When we think of embers from a great fire we tend to have a sense of fear. There is an element of the unknown, because not only are we watching what a fire is destroying but we are holding our breaths anticipating where the sparks and embers will float to….what it will destroy or forever change —next. I used to feel this way, but as I have traveled through Dante’s Nine Circles of Hell the past two years I have begun to look at embers as quiet unpredictable magic. When you think about it embers can do one of two things: Start a new fire or softly, gracefully land somewhere on something and release the last of its glow, becoming part of the dust in the earth—contributing to the creation of something new. I have stopped waiting with baited breath for the next fire and have begun to associate the flakes of fire as the breadcrumbs I need to help me make it out of the Inferno, into to the Purgatorio….and eventually the Paradisum. Embers can indeed be life’s magic wand. The following is an example of how I’ve l earned to just sit back and watch where they will land—preparing for the worst, hoping for the best, and remaining ever present in each moment of my life.

I never went to my high school proms or to homecomings–-I always yearned to be asked in some special way like you see the kids do these days—the star quarterback planning how he is going to “pop the question” in a way that stands out in case there is competition….usually spelling out the word “Prom?” on a huge brick wall at the school or using rose petals to ask the question covering his girlfriend’s eyes with his hands as he guides her out to the backyard, her parents looking on with a mix of pride, tears and excitement….taking pictures, preserving memories. I never participated in those rituals—spending a full day at the spa getting hair and makeup done, mani’s pedi’s with best friends, taking photos they now share today….excitedly chit chatting, anticipating the nights events….or who would be crowned Homecoming King and Queen or Prom King and Queen. I admit–I looked on with envy *all the time* as the cheerleaders cautiously adjusted their court sashes over their freshly pressed uniforms before the assemblies and games, with such care you would think that the ribbon would fall apart if they tugged just a bit too hard. I thought those sashes were the blingiest  things in the world back then and I would often close my eyes and pretend what it would be like to be on the arm of a handsome football player at halftime in my cheerleading uniform, participating in the Homecoming events….knowing there was a full night a parties ahead to attend and look stunning for.

About a month ago, I had the night that made up for the Homecomings, Proms and parties I missed out on. You see I was pretty overweight in junior high and a pretty mousy run of the mill wallflower in high school that really just blended into the brick walls most of the time rather than stand out. But on this night the star quarterback was MY date……for this night,  HE chose Me. To say I felt exhilarated at the prospect of being out with this guy is to completely diminish how excited I was in the days proceeding the party Id be attending with him. I fretted over what to wear, my nails, how I’d wear my hair, what shade of lipstick I’d don that night in the hopes of getting that  ”WOW look” when he arrived to pick me up. When the day arrived I couldn’t have been higher in the stratosphere. Anaya insisted on doing my hair (I’ve never let her do it before), she inspected my outfit choices, told me what to do and what to say and what to absolutely avoid doing at all costs. Before I knew it nightfall had arrived and though I had intended to take a nap to appear all nice and rested that plan had been abandoned hours earlier in exchange for pacing around the mall to make sure I hadn’t missed “something better” to wear.

Then, there he was. Exquisitely beautiful, a voice that could bring a room full of women to their knees, a commanding yet gentle energy/presence…. As hard as I tried to hide them,I know I had stars in my eyes– as he reached out to hug me. He smelled more delicious than any guy should be allowed to and I felt lucky to have remained upright when I felt my knees give way —he had jolted awake every sense. I sat there in the passenger seat feeling thrilled…. wondering to myself how I was getting this second chance to live out those moments I missed out on at Cactus High School many years ago.  So this is what it felt like……This was *the guy* and I was *that girl* and we were going to have *one of those nights* I knew I would never forget the rest of my life. Though the evening didn’t proceed as I had imagined, hoped,  and dreamed it would…..I later realized that this beautiful night wasn’t about *that.* It was about getting that second chance to experience magic resulting from the embers of a great fire.

This night was about realizing that the embers of a fire have the potential to do more than destroy—they have this way of giving you another opportunity to live out moments in life you didn’t take the opportunity to before—and to appreciate how quickly life passes by when you don’t take chances and get out there and do it up right….you miss out on some of the most phenomenal and brilliant experiences life has to offer. I know that I will remember this guy for the gift he gave me that night—the gift of appreciating “being in the moment” and taking in every sense……everything about my surroundings….his beauty, the thick sweet voice, passionate soul, and my wonderful loving new friends…..See, that night was about what life “is” when you just take the time to put all the ugly destructive stuff off to the side and really see the beautiful peaceful clearing ahead….taking one step at a time…..taking a chance and realizing your dreams can come true just as much as anyone else’s. Someday…I hope I can thank the “star quarterback” that was at my side for that evening—  for fulfilling a dream and letting me swirl around in the warm sweetness of it all.  I was the Homecoming and Prom Queen all in one night. Who gets a second chance like that? (Smile) I did……………

Nurses Week 2013: “White Out!”

Nurse Week 2013 “White Out”– One profession, One voice, One vision, One journey toward a healthier profession.

Are you on board? Let’s hit up the American Nurses Association to proclaim a theme with meaning this year, a theme that calls on each one of us to both love and heal the broken hands and hearts of one another, a call to action that mandates we all take a stand together as ONE to care for ourselves and give to eachother whats so important to give back to our patients…….what we lack, as nurses, as humans, we cannot possibly give to another human being……

Lets take back OUR WEEK from those who have taken it from us—-no more “hospital week” or “health provider week” no more tacky cold clinical swag with the hospital logos on it—instead lets take a week this year to explore healing activities that help us to communicate better and treat eachother better. Let’s take this week to explore the meaning of compassion, teamwork, passion for caring, and what “healing” means for each one of us in the workplace. Nurses Week 2013 should be about taking a momentary pause to reevaluate where our profession is at, and where we are at within the profession…..how are each one of us contributing or not contributing to the spirits of our coworkers and to improving our workplaces????…….No more spongy tasteless cake this year —WE are worth so much MORE—Our bodies, our minds, our spirits, the hands with which we administer to people…..are worth MORE than a fanny pack or a tacky  mug and a pat on the head telling us what good little boys and girls we are. It’s time to set some goals and take the first steps back to basics. Lets begin to transform our workplaces and do our part—individually and collectively. We already know that Nursing is a severely fractured profession so its time to make healing priority #1.

Let’s all wear white for Nurses Week –“White Out 2013″ a reminder of our roots, the time honored tenets we were taught….lets start the care plan our profession so direly needs right now. Bring back the white scrubs, the white dress, the white shoes, and the white caps for one week of solidarity…..that will hopefully spark a more promising future for our young. If you agree, cross post this everywhere and give the American Nurses Association a chance to prove just how much they care about what WE need out here in the trenches. If the ANA doesnt give its blessing I will be campaigning to declare this theme here in the western part of the nation—at the very least. I dont recall that there is a rule ANYWHERE that says nurses cannot declare a Nurse Week Theme on their own or that any other nursing organization cannot do the same. But the ANA is  ”the voice of nurses?” No, they are not. If they were, our health status as nurses wouldn’t be at the low point that it is, our workplaces wouldn’t still be as toxic as they are, and nurses would not be subjected to retaliatory behaviors and their lives stripped away for doing what we were educated and licensed to do for people everyday—-and I’m willing to guess Florence Nightingale would rise up out of her grave with a fist in the air telling us all to take our profession back—for us, for the future nurses, and most importantly for our patients. 

Amanda Lucia Trujillo MSN, RN
Nurse Advocacy Awareness and Support of America (NAASA)
National President and Founder
Phoenix, Arizona

I am a tugboat. What are you?

 I was recently engaged in a rather lively debate with a few of my peers when a  statement was made that I found especially troublesome considering the current state of our profession. My passionate opponent charged me with having those pesky “delusions of grandeur” again— only this time I was guilty of  assuming “I alone” could take on what “I believe” to be a broken system, and that to make a difference one must have the help of others. I halfway agreed with their position. First of all I “don’t believe something is wrong” I know something is wrong with our profession.  A thorough literature search in any University’s online catalogue will yield piles of peer reviewed research on the subject. Lets make something clear—I don’t talk out my ass. If Im discussing something like the mortality rates for CHF patients or the dissatisfaction of nurses or the overuse of IV antibiotics and their contribution to nosocomial infections—Im not pulling facts  out of the air around me.

I know that any one of us in the nursing world can do something to make a ripple in the water. If each one of us makes a single ripple in the water all of those add up to a mighty strong current—which could serve as a catalyst for big changes. So, I believe all it takes is one person to start asking the questions, begin speaking up and reaching out, yell out loud “ENOUGH!”—you don’t have to have an organized team of people to get the change process started in society, especially in an age where social media is center stage to what will be some of the biggest changes our world has yet to even comprehend.

We do, however, require the talents, education, and passions of each other to assist in the journey and to help accomplish the desired results. Those of us on Facebook and Twitter are bombarded on almost a daily basis with inspirational quotes urging us to make a difference in the world, walking your talk, not giving up, living your truth, daring to dream. Does anyone pause to remember where these quotes came from? The people who have spoken these words are some of the most humble yet powerful and influential people in the world—Mahatma Ghandi, the Dalai Lama, Mother Teresa, Pope John Paul II, Sidney Poitier, Oprah Winfrey, and Maya Angelou to name just a few. Do you think Nelson Mandela asked permission to make change or that President Jimmy Carter sits and waits for others to come and help him make a much needed difference in the world with his volunteer work? Do you think they sat on their hands and waited until they could get just enough people to “agree” with him before saying “enough!”

Change, in its most elemental form is energy that manifests in many ways—it could be single voice rising above the others with a yearning to make a difference. In its most primitive state, “change” is simply harboring hope and faith for something better. Nurses. You do not need a group of any size agreeing with you in order to take on the biggest of issues that continue to plague the health of our nation’s people. All it takes is a decision and the determination to act and that the motivation for your actions be for the greater good of the masses and not just a select few. The most controversial individuals in society today happen to be the most celebrated— not for what they do (or did) that left an impression on the world but for the sheer audacity they possessed, breaking through barriers—and refusing to accept the word “No” for an answer.

The lovely thing about blogs is that I don’t need anyone’s “blessing” to publish something. I don’t need to run to my nurse manager’s office and plead for a spot in the monthly corporate newsletter to say what I feel nurses need to be aware of hoping they wont censor 80% of it.  I can write about nursing issues, or workplace issues and I click “publish.” Voila, no approval process needed from an archaic journal staffer and my words make it all over the world. I don’t need to be popular or a member of the nursing “in crowd” to get my message as a nurse out into the world either. I have never gone to work with notions of being little miss popularity, excited at the opportunity to go to lunch with the “senior nurses” or to parties after work, climbing over heads to grip onto the “holy grail” of nursing positions—management;  nor was it enticing to me to be pulled into the little huddle at the nurses station where the latest taboo conversation centered on who was “doing who and where.”

I went in to nursing with grandiose (that’s for all of you who love that word so much)   ideas of helping every day people take better care of themselves, learning everything I could to be a better practitioner, and making the commitment to be a lifetime learner. I had dreams of making changes in our profession even though I didn’t know what those were just yet. I make no apologies here—Ive lived my nurse life out loud. Ive lived it from a place of honesty, and there has never been a question about where I stand on any issue. While this a trait some don’t appreciate in me, it was (and is) a trait that has endeared me to others. The sweetest part of blogging is the freedom it has afforded me, for the first time, in my nursing career. Though I always remained steadfast to who I was as a person and as a nurse I never felt free to completely say my peace for fear of upsetting this person or that person. Here, in this space, I can use my education and experiences to really grow into who I was meant to be as a nurse all along. I can put it all on the line to create something new and different….the possibility to make change for my colleagues and patients is much more real, attainable, and tangible than it ever could have been inside the walls of a corporate entity.

Every day each one of us makes choices about how we will live life.  We present a total package to the world in the way we see fit —whether it be loudly or not. Its called individuality people. Within each one of us lies something no one else has to bring to the nursing table. Amazing, phenomenal, colorful, sparkly things. What I see happening is this great effort on the part of many to dim the lights of creativity, passion, and hope within our profession. Minimizing the colors of the millions of lights around the world to just a chosen two or three greatly deducts from the beauty and possibilities that lie in wait for all of us as humans living in a complicated and stressful world. Aside from that, who should be charged with the task of deciding that there “should only be two or three colors of lights all over the world?” I could pose this same question to our profession. Who has decided that it is wrong to speak up or speak out? Who has mandated its improper for a nurse to take a stand for an injustice? Is there some ancient Decalogue out there Im not aware of that sets the precedence for who we will or will not support when a colleague is under fire by “the system?” If there is one, my guess is that it is under careful watch in the basement of the ANA headquarters. Secrets, after all, are sacred in our profession. But really, who has slammed the gavel on the table that set in stone a law mandating all nurses must look alike, act alike, believe the same things, talk about the same things, and have the same ideas? Who carved it into the proverbial old oak tree that nurses aren’t allowed to talk about what we see or hear or are a part of if it means that someone is getting hurt or someone is going to get hurt if we don’t? Who decided we cant be heard or our talents used?

….Imagine Nursing devoid of any individuality, creativity, color, or potential. Visualize it as just one big, long algorithm on a sheet of pristine white paper…. a Times New Roman font, Black and white ink, justified at the center of the page….arrows pointing to “do this when that happens….”  NOW, hold that algorithm up next to a real, live, human being. It’s 2013, and this is where we have arrived as a profession—fault not only lies within the walls of hospitals and the 1,000 page insurance company manuals that dictate what we can or cannot do for our patients—it lies with us too. We have passively handed over the reigns of our profession and its future to people who have no business leading, restructuring, or defining who and what we are. Why? Because collectively we have submitted to fear, intimidation, and silence–putting paychecks ahead of our oath. Many within our ranks have abandoned a sense of ethics or the oath they took early into the nurse journey in favor of remaining ships that sit idle and safe in a harbor….heavy with precious cargo that are hidden and protected from the world. But, as the saying goes….ships weren’t meant to sit idle and safe in  a harbor, they were meant to go all over the world and exchange cargo….dropping off old treasures and aquiring new ones to share at the next port—each time, leaving that place  forever changed because of the treasures it left behind. A question I’d like to pose to every nurse who reads this—-are you that big beautiful shiny new ship playing it safe in the harbor and depriving the world and your patients of some really great things or are you that fearless tugboat breaking the ice and forging a path for others to follow……..the choice, of course, is yours —but don’t be *that nurse* whining during this year’s Nurses Week about all the ridiculous, redundant swag or lack of recognition if you aren’t willing to step up  and outside of yourself to do your part for patients,  our present, and our future.

“No Whining, No Crying, You got this, just do it.”

I’ve missed my trainer *a lot* lately, wishing he were here to push me through shit like he has been the past few years. But, as I went up and down the stairs this evening at GCC Stadium I realized something. Perhaps he prepared me to go it alone. I mean, none of us is guaranteed forever with anyone—even our trainers, hairdressers, or nail ladies. Life moves us in different directions, and though I know he doesn’t care for me any less nor does he wish for me anything less than the best in life, maybe he really has given me the best gift anyone could—the ability to go it alone and push myself past this period in my life. I’ve gotten so used to having that proverbial cheerleader there, at the ready, with all the motivational words, hugs, and cheerleading when I needed recovery from Cushing’s, Surgery, and all the drama that occurred with McBanner Health and the Arizona Board of Nursing. I got to the point where I wondered what I would ever do without my trainer as a daily fixture in my life. That all important “backup” the “emergency generator” of confidence and validation when I needed it and even the one person in this world—yes, the ONE person in this world I would allow to give it to me how it is and tell me the stuff I really don’t care to hear nor would hear from anyone else. And then, as life does, I wake up one day and find it’s time to do this alone, without my cheerleader.

It’s time to be my own cheerleader, my own trainer—I have done it before and he has given me even more tools to do it again and to do it even better. So, tonight, I sat down by myself on the football field with a piece of paper and pen and wrote down all the things he used to make me do for interval training and looked around the stadium to see where I could mimic those same things. Then, I came up with a plan, folded up the piece of paper, securing it with the pen, and put them both in my jacket pocket. I could hear him in my head saying “no crying, no whining, just do this.” Taking off my jacket I pulled up my “boxing/cardio” playlist on the iPhone, donned my favorite BOSE headphones and put one foot in front of the other…..with every bit of confidence that if I did it in the studio, I could do it here….in this stadium, alone, with my own soul, my own thoughts, and my own raw determination. I brought my boxing gloves with me and used the gates as a punching bag, the track team left their equipment out on the track so I used those to do my sidekicks, I did lunges on the football field, and I even discovered I could still run like the old days…..only, I need to better secure the 38 DD’s……and of course, I did the stairs. I remembered to do everything at an interval like he used to make me do it in the studio and 45 minutes later I collapsed on the football field, on my back….spent, feeling accomplished, staring at the stars. Just like the old days at NAU….with the stadium all to myself.

Having accomplished this alone tonight I know I can do it again tomorrow morning after I drop off Anaya at school…..and the next morning….and the morning after that…..I used to hear him say—“you got this mami, you got this, no crying, no pain, just do it.” Though he can’t be here now, he’s always in my head when it comes to training and in what I have learned from him during the most difficult days of my life. I think God has a way of putting us in the position of having to stand alone for the very simple reason of showing us when left to ourselves we can accomplish anything if we really want to do it…..so just like I had a standing appointment with my trainer several days a week—each morning will be that standing “appointment” with myself, the stadium, and God when I go out there and interval train….I’ve really missed the boxing gloves. Now that I’ve put them back on again, I do believe its time kick a little ass and show the haters what I got.  I will admit though, I miss his bear hugs, and hearing his heartbeat. I always knew everything was going to be okay….Maslow people, we all are subject to the hierarchy of needs…..no matter how strong, or hard, or resilient we try to be or how much we try to bear upon our shoulders…we all require the same basic fundamental things…..

Veteran’s Health: Nursing CE

While I commend (I’m not going to use the word “applaud” for obvious reasons) Nurse.Com for bringing attention to the very HUGE need for nurses to learn more about the needs of our veterans Id like to take this moment to remind everyone in our profession  that one or two CE’s by NO MEANS even covers the complexity of caring for our veterans—as of yet, there is no evidence based research to support a framework for practice to guide us in treating veterans with traumatic brain injury, combat loss and bereavement, post traumatic stress disorder or any combination of the above. THIS is WHY nursing care plans are imperative in our daily practice!!! How else can we uncover existing themes in the day to day care of veterans? The theoretical underpinnings of frameworks for practice come from what we discover with each and every veteran every day we work with them. More importantly—its important to ask during your admission assessments—”have you served in the military or are you currently serving in the military?” The answer to that question…..could be a complete game changer in your approach to providing best care and anticipating needs in the acute care setting and potential needs for ongoing care out in the community…….Want instant rapport with a Veteran? Take my word for it—-when you do your admission assessment and ask them if they are a veteran and they respond “Yes”—Make meaningful eye contact, put out your hand to shake theirs, and tell them “thank you.” Works for me every single time. And for anyone out there who would like to question my experience with vets and their needs—-I am the daughter of a Vietnam veteran who came back pretty messed up and have had to learn the ins and outs of living with a father trying to find his way after war my entire life. There is so much to think about and consider when taking care of these men and women. Keep  learning…..it’s our turn to give back!!!!

Behind Closed Doors: Is it just me….Or is it the system? Case #7

Information: Plantico v. Froedtert Memorial Lutheran Hospital

Summary: Was the hospital liable for death of patient via OxyContin?

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe nursing practice. Thank You.

(Published with permission from nursefriendly.com)

     It’s that time of year again. Elbows resting on the counter and chin in your hands you watch as a fresh batch of residents floods the nursing station appearing painfully awkward as they fumble around with their newly issued phones, metal clipboards,  and pagers, nervously glancing about for a place to sit, while trying to appear as if they have been doing this for years. You and your colleagues know better. For the next two months all the nurses will have the “unofficial” pleasure of making sure the orders these neophytes write make sense and don’t have the potential to kill any patients. You’ve lost count of the many near misses that have been intercepted in the past, and have no intentions of letting anything slide by you—the veteran nurse on this floor. But today has been unusually busy. You had one code blue that went to the ICU, another heart failure patient flown in shortly after that who now has a SWAN ganz catheter, two drips to manage, and hourly cardiac outputs; a fresh thoracotomy from the PACU, and an acute stroke patient who has been admitted to the floor because he is actively dying and there are no beds on the 6th floor where end of life patients (that aren’t heart patients) are usually admitted. The family is understandably in shock and requires a lot of your time and support. Upon returning to your desk you find a new report sheet with details of yet another patient who will be added to your group. It’s an LVAD patient coming in because his flow readings aren’t looking normal and the doctors think he needs to be rehydrated or transfused. Awesome.

     While making rounds and checking on everyone, you notice something isn’t quite right with the patient who had the thoracotomy. She has a patient controlled analgesia pump running and you double checked (with the PACU nurse) all the settings upon her arrival to the floor. No adjustments have been made to the pump since then. “Mrs. Beatty how are you feeling right now?” you ask. “I just feel so drowsy, like my head is somewhere above my body” she responds. She says her pain level is a one. Her vital signs are okay with the exception of her respirations which are 12-14 per minute, and her oxygen saturation which is 92% on 2 liters of oxygen via nasal cannula. One of the prongs is out of her nose. While readjusting the nasal cannula you advise her:   “I’m going to increase your oxygen a bit and raise the head of the bed to allow you to breathe in a little deeper” Eyes closed, she nods in agreement, and begins to snore. Mrs. Beatty’s oxygen saturation picks up a bit and rises to 96%. Her respirations are now 14-16 breaths per minute. You feel only halfway at ease, because your nurse gut is still whining, taking up space in your head. You sit down in a chair to think when the nurse iPhone alarms, signaling that it’s time to go shoot another round of cardiac outputs on the sick heart a couple of doors down. Shaking off that nagging feeling, you take one last look at Mrs. Beatty’s oxygen saturation monitor (it’s 95%) and leave the room. You’ll check on her again when you get done with the outputs and call the CT Surgery Resident, perhaps the settings on the PCA pump need to be lowered.

     One of your colleagues enters the room where you are attending to the sick heart patient, who, himself is starting to worry you because his numbers don’t look good and neither does his heart rate…. “The family in 324 is asking for you, they think something has changed.” Thanking her for the advisement you make a mental note to call the heart failure team overseeing this patient and you head down the hall to the room where the stroke patient is actively dying. The daughter is waiting for you at the door, tearfully sharing that her father seems to be “struggling with his breathing” and is having a difficult time. A quick assessment reveals that the patient could be experiencing air hunger. His respirations are 18 per minute at the moment but he is indeed struggling to breathe and his body is showing signs of tension. You reassure the daughter that there are standing orders for morphine to help relax her father and make him more comfortable. After administering the morphine you sit at the bedside for a few moments to assess its effect on the patient’s breathing. His respirations slow to 12 and they are deeper, his body begins to relax. The frightened family members in the room gingerly approach the bedside once more to continue their vigil. You sense this is your cue to leave. But before you exit, you bump up the patient’s  oxygen to 4 liters per minute and ask the family to call for anything else they may need.

     Before getting distracted with anything else you quickly dart into an empty room to page the heart failure team and report your concerns about their patient. Relieved that they will be up to see him in the next five minutes you take a moment to decompress by leaning back into the chair, closing your eyes, taking a deep breath and begin counting to 100.  Somewhere between 45 and 50 a pulse oximetry alarm goes off and you hear the sound of feet running down the hall. Reluctantly you pull yourself up out of the chair to investigate which of the nurses might need some help. As you make your way to the nurse’s station yawning and stretching you hear “Mrs Beatty wake up! Mrs. Beatty you need to breathe! Mrs. Beatty can you hear us?” A code blue sounds overhead. Grabbing her chart you run into the room and find your coworkers initiating CPR and placing a bag valve mask on her face until the code team arrives. You learn that one of the nurses came in to check on Mrs. Beatty when her pulse oximetry alarm went off and she found the patient slumped over in bed barely breathing.

     The code team arrives shortly thereafter and with chart in hand you answer their questions about the patient. They inquire about the PCA pump settings and you provide them with the orders the CT Surgery Resident wrote earlier when the patient came to the floor. One of the code team nurses yells out “What? A background rate? The pump is set to a demand dose and a background dose? No wonder she coded!” That nagging voice in your head is now screaming “See? I told you to look harder! I told you something was wrong!” You’ve known that patients on this floor never have a background dose of narcotics infusing at the same time as the patient is obtaining a demand dose of the narcotic every time they press the button. It’s clear Mrs. Beatty has been overdosed. How could you have missed something so obvious? One of the code team nurses calls out for Narcan.  Mrs. Beatty responds to the medication and wakes up, but her respirations are still slow. “Let’s roll everyone” says the doctor as he heads out the door, plucking the chart from your hand. He pauses, and returns to your side, putting a reassuring hand on your shoulder. “It happens to the best of us,” he says. Before you know it Mrs. Beatty is packaged up and rushed out of the room to the ICU. She dies two hours later, during shift change. Right then you don’t care to ever take another breath. You feel so sick and shocked it’s a painful struggle to get through shift report. All you want to do is be a fly on the wall, or curled up in a dark corner away from everyone and everything. The nagging voice is back, only now, with an ominous message: “This is bad……real, real, bad.”

The Real Thing

Patricia Plantico was admitted to Froedtert Memorial Lutheran Hospital for back surgery to help with chronic back pain she had been experiencing. Her physician, Dr. Maiman wrote orders for morphine to relieve postoperative pain. Patricia did not respond well to the morphine so Dr. Maiman ordered Oxycontin 80mg, to be given by mouth every twelve hours. Patricia received her first dose of the Oxycontin at midnight. About 9:25 the following morning she summoned the nurse to report feeling “shaky, nauseated, and overmedicated.” At that point she was given another 80mg tab of Oxycontin, which incidentally—was not supposed to be given for another two and one  half hours. Records show Patricia’s call button was pressed sometime between one and two in the afternoon. Around two in the afternoon a nurse found Patricia unresponsive. A code was initiated, Plantico was transferred down to the intensive care unit. She was maintained on life support for a period of five days before she died.

Questions to Consider:

1. 1.     A physician writes an order for a pain medication. The dose is much larger than what you are accustomed to seeing. You know this doctor has a history for throwing charts in the nursing station when he gets questioned. What do you decide to do, and why?  
2. For a post- operative back surgery patient such as the one above how often would you be assessing pain and/or level of consciousness? Would you be interested in objective data more than subjective, or would your impression consider both subjective and objective assessments? Why or why not?
3. Is the nurse primarily responsible for the decline of this patient or is the physician? Why?
4. Could pharmacy have had a part to play in this unfortunate scenario?   How?
5. Do you see this situation as one that faults one or two people or the current system in place?
6. Take a break from the blame game and construct a pretend root cause analysis—consider all points at which the ball may have been dropped. Keep in mind that errors of this nature are rarely the result of one person’s miss…rather….it’s the system itself in need of improvement. Find solutions to the problems you identify.

Discussion

The case notes made no mention of Patricia’s age. I couldn’t find any information about whether the nurse caring for the patient was a newer nurse or a veteran, or whether there were any other mitigating factors. What this case screamed out to me was “systems error.” Did the hospital have a policy or pain protocol about dosage ranges that could be given to post- surgical patients? Was there an assessment protocol to follow to ensure proper monitoring of patients on medications like this one? (Q 2 hour pain and LOC assessments) Did the pharmacy have a safety feature in place to catch unusual doses such as the one mentioned above? Medication errors continue to be the number one cause of patient care errors and their incidence far under reported: “The contemporary epidemic of medication administration errors has proven to be impossible to quantify. According to the Institute of Medicine (IOM), medication administration errors are the most frequently identified medical error in the United States (IOM, 2000, 2007). Nevertheless, it has been estimated that less than 5% get reported(Cohen, Robinson, & Mandrack, 2003). The number of errors, however, varies with the definition, identification methodology, and method of reporting. Still, one thing is certain: this problem has the attention of health care governing boards. After reviewing numerous studies, the IOM (2007) concluded that “a typical patient would be subject to one administration medication error per day” (Treiber, 2012)

The nurse(s) involved in this case could very well have asked around as to whether or not the 80mg OxyContin was a “normal” medication dosage seen on that unit and could have been told “yes.” We could go on and on about all the different things that could have occurred, but much of it we will never know. What is important to ask is “if we looked at this case from a broader standpoint where could improvements have been implemented?” Nurses experience numerous interruptions during a patient care day and much research has demonstrated their impact on patient safety: “Interruptions of any magnitude can have dire consequences to patients. One study reported that nurses were interrupted up to 10 times per hour, or once every 6 minutes, which resulted in an overall error rate of 1.5 per hour… Nurses solve problems in real time, and it is often necessary for them to modify their planned assessments and treatments to adapt to environmental demands and changes in patient conditions. Accordingly, the nursing process is nonlinear and requires constant partitioning, interweaving, and reprioritizing of patient care. Therefore, interruptions of any magnitude may affect patient safety.”(Rochman, 2012) It has been suggested that developing simulation exercises to engage nursing students prior to introducing them to the “real nursing world” has helped to familiarize students with the realities they will be facing while trying to multitask, solve problems, and provide safe care to patients.

Holistic assessment and root cause analysis can easily combine to begin the problem solving process. For those of you who have just heard the terms “Root Cause Analysis” or have seen the three letters “RCA” but have no clue as to what they mean or whether the concept is even pertinent to your nursing practice—listen up, IT IS: “…Though there is no generally accepted definition of what a Root Cause Analysis is, a possible definition could be ‘a structured investigation that aims to identify the true cause of a problem and the actions necessary to eliminate it.  A Root Cause Analysis is not conducted using a single tool or strategy, rather, a number of tools often used in combination.” (Anderson & Fagerhaugh, 2000) We nurses have been trained how to perform holistic assessments on people, why not apply it to the scenario? Start with one simple question: “How does an 80mg dose of Oxycontin make it to a patient, furthermore—how did two doses of this medication make it to this patient?” From there, you brainstorm about all the possible things that could occur or make the clinical setting “just right” for this sentinel event to happen. For instance, was there a staffing issue? Was a nurse working overtime? Was there a transcription error?  Was the doctor exhausted and at the end of a four day run of shifts? You get the idea. Now, find solutions. A holistic assessment of the scenario could be used as an effective root cause analysis tool!

Most of the major sentinel events we catch wind of via the national news circuit are rarely the direct result of a nurse’s error, and the naming of the nurses involved does nothing to solve a tragedy—in fact it inflicts trauma upon the nurse and his/her family—for life.  It’s imperative that we begin the shift from “blame” to “rename.” Rename the problem for what “it” is and not “who” did what. “Since it is the nurse who has the responsibility of administering medications to patients, the nurse has often assumed or been assigned blame for these errors. In reality, there is usually a chain of events leading to an error. Medication errors are seldom the result of one person, but involve the actions of everyone caught up in the system, including the designers of the system.” (Maurer, 2010) We as a profession accomplish nothing by throwing nurses out to pasture for falling victim to the human condition. Nurses demand perfection from one another—and anything less is deemed a big “F” for “failure.” We must learn to make use of learning opportunities as a means of breaking the cycle of blame and initiate a new practice of problem solving that will prevent harm to the patient (and trauma to the nurse) while introducing a just culture that is so desperately needed in the corporate healthcare setting.

Works Cited

Plantico v. Froedtert Memorial Lutheran Hospital, 647 N.W. 2d 468–WI (SUPREME COURT OF WISCONSIN July 26, 2002). Retrieved October 15, 2012

Anderson, B. &. Fagerhaug, T.(2000). Root Cause Analysis: Simplified Tools and Techniques. (A. Koudstall, Ed.) Milwaukee, Wisconsin, United States: ASQ Quality Press. Retrieved October 15, 2012

Maurer, M. (2010). Nurses‟ Perceptions of and Experiences with Medication Errors. Toledo: Proquest. Retrieved October 15, 2012

Rochman, M. A. (2012, July-September). Interprofessional Simulation on Nurse Interruptions. Journal of Nursing Care Quality, 27(3), 277-281. doi:10.1097/NCQ.0b013e31825734b4

Tammelleo, A. D. (2002, October 1). Hospital’s liability for overdose of OxyContin. Retrieved October 15, 2012, from The Free Library: http://www.thefreelibrary.com/Hospital’s liability for overdose of OxyContin.-a094159002

Treiber, L. &. (2012, June 7). Devastatingly Human: An Analysis of Registered Nurses’ Medication Error Accounts. Qualittive Health Research, 20(10), 1327-1342. doi:10.1177/1049732310372228

Lessons of a Political Toddler: What you see isn’t always what you get.

My attorney, knowing I had been trying to meet and speak with Senate Candidate Richard Carmona (the former US Surgeon General), was kind enough to forward me information about where he would be speaking this weekend. To say I was thrilled is an understatement. There are several reasons I have been happily riding along on the Carmona Caravan for quite some time:

1. He grew up in a poor Latino family
2. He was raised by a single mother
3. He is a Vietnam vet like my dad
4. He was a nurse.
5. The campaign commercials won me over with his assertion that healthcare is neither a Republican nor Democrat issue. We have to come together for solutions.
6. He is not Jeff Flake nor does he even bear a close resemblance to Jeff flake

Beautiful right? All things to pull me out of the house during the day (which most of you know I despise)—and with full makeup and hair no less–an everyday miracle. I was up early, thinking of the questions I wanted to ask and trying to pick out an outfit that would look great for a photo-op with this guy I had really come to admire as a Latino leader. Today I was going to be representing the voices and concerns of nurses directly at the bedside, the ones in the trenches. Over the past weeks I have been talking to my politically astute 16 year old daughter about Carmona, though I was unable to drag her out of bed this morning to go hear him talk because Homecoming was last night….

I set out early, caffeine in hand, and made the drive to the venue. I took lots of pictures of Dr. Carmona talking and the official campaign signs—excited about posting them all over my Facebook page later in the day. All of a sudden, someone took a needle and rudely popped the bubble I was so happily floating around in. The hard landing to the floor was not pleasant. Dr. Carmona’s speaking abilities as they pertain to his life story and numerous, admirable accomplishments and qualifications are enamoring. (This portion of the talk also took up a good chunk of time during the event) I don’t need to hear what I already know from the commercials running 10-12 times a day on the television. I want to get down and dirty and hear people engage in discussion about what Richard Carmona is going to “do” for “us” his constituents. I was disappointed to hear many of his responses begin with “we have to do” instead of “As senator I will do, I will advocate, I will push for, I will work to.” At one point he made reference to Jeff Flake not being familiar with the district he represents or the people in it. I’d like to pose that today’s speech by Carmona was an eerie parallel to Flake’s disconnect from the real folks out there dealing with the issues of healthcare reform and access, immigration, the dream act, veteran’s health, the ailing economy, job loss, education, and of course—the struggles of our nurse workforce .

A Bloomberg reporter asked me “what did you hear” from Carmona today? My answer: “Nothing much.” Carmona gave beautiful answers when asked about veteran health, immigration issues, border safety, and the dream act—his passion for these particular issues is readily apparent. The answers were from the heart. I was there for something else though. My nurse colleagues and the people we care for and protect 24 hours a day seven days a week. I wanted to hear verbs in his sentences. I needed to see some concern in his eyes for our safety. What was Richard Carmona going to “do” for us, the approximately 115,000 nursing professionals actively practicing at all levels of the profession in Arizona. What was Richard Carmona going to “do” to protect us from retaliation so that we could do our jobs? What was Richard Carmona going to “do” to ensure nurses could practice, without fear, to the full extent of their licensure and education in the state of Arizona?

The answer (or lack thereof) was the proverbial needle in the pretty, shiny, red heart awareness balloon that’s always floating above my head. Carmona quickly diverted from my questions by saying he would work with the state board to protect the scope of practice of nurses in Arizona, and even made a vague statement about not being able to really say for sure what he could do about retaliation concerns. The canned reply was equivalent to what Senator John McCain did to me when he sent me that zinger of a form letter reassuring me of his appreciation for me writing him and that he “would forward my concerns to the state board of nursing.” What? Dr. Carmona’s reassurance that “I have already addressed the Arizona Nurses Association” did nothing to comfort me either. Actually, it felt more like someone was pouring salt and lemon juice over a second degree burn.

If you are a nurse in Arizona you know the AZNA is primarily comprised of nurse management, administrators, state board members,  and instructors from all over the valley, most of whom haven’t been at the bedside in ages and are up there somewhere in the stratosphere of our profession—completely disconnected from those of us at the sharp end of patient care. (It’s actually sharp at both ends—we get hurt and patients get hurt) Dr. Carmona clearly hasn’t researched the fact that less than 4% of all nursing professionals are actually members of the Arizona Nurses Association. They are not the “collective voice for nursing” as they so proudly boast. Addressing the AZNA at an AZNA breakfast is not addressing the critical concerns of the nursing workforce in Arizona. I wanted to know what he was going to do to protect “the rest of us” in a right to work state and at the federal level. No answer to that. I went on to ask how he was going to enforce the recent recommendations of the Institute of Medicine pertaining to nurse scope and the overlap between nurses and physicians. Mid question I was waved off and told “I have other questions to answer.” Perhaps the AZNA gave him just enough of their kool-aid or warned him about this “psycho nurse named Amanda Trujillo running around causing trouble.”

Right away it occurred to me—Carmona is no different than any other nurse who hasn’t been at the bedside (AS A NURSE) in numerous years. He is out of touch with the issues we face–TODAY. He is nowhere close to understanding the dangerous settings we practice in and the unethical dilemma we are forced into when we have choose between the lives of our patients and our paychecks/livelihoods.  His campaign commercial is real neat and filled with hope—but I think its appeal is that it speaks to people in all demographics, it perks up your ears, grips your attention—and your heart. Well, I was drawn in a long time ago and what I heard today was a candidate who was staying nice and safe in the middle of the road with well prepared, rehearsed answers—Carmona appeared neither here nor there unless addressing issues he is clearly passionate about. I received more concern and support at the Hispanic White House Initiative in January.

Another hard lesson in politics for me, the political toddler: What you see isn’t always what you get. Just because a candidate shares the same characteristics as you; like background, ethnicity, or occupation, doesn’t mean they are going to be the best one to send to Washington. Dr. Carmona’s accomplishments are truly remarkable and inspiring, as is his life story and journey. He is a remarkable person. In fact I feel like I could kick back on the porch in my backyard with a margarita and listen to him talk about those things all day and never hear enough stories/experiences from his life. Richard Carmona is an extraordinary individual with a commanding presence and it’s clear to see how he has constructed such an inspirational life.

Unfortunately, Richard Carmona will not be the candidate that will go to bat for the nursing workforce in Arizona or at the federal level, and furthermore, he doesn’t seem to understand that the State Board of Nursing does not advocate for the nursing workforce or work “for nurses.” He is nowhere near in touch with the issues affecting bedside nurses in hospitals. It’s easy to see how he may have been misled to think he has addressed nursing concerns because of how many people he’s met who are members of both the Arizona Nurses Association and the State Board of Nursing. It would be both refreshing and inspiring to see Richard Carmona reach out to the nurses in the trenches—the people he talks about as being downwind, out there in battle, on a mission to achieve, the ones he wants to help support. Well, Dr. Carmona, that’s me. A single mom, a Latina voter with both a Bachelors and a Master’s Degree (working toward a Doctorate) in the unemployment line and relying on state assistance because there was no one in government or anywhere else to protect me or any other nurse when it comes to doing what we earned a license to do and abiding by the oath we took.

Dr. Carmona relayed his concerns about the lack of highly educated Latino leaders in the workforce. Well, Here I am Dr. Carmona. One of the few you talked about “who made it out” one of the few who “went all the way” through school and accomplished getting into the workforce to make a living and make a difference. Here I am, Dr. Carmona, taken out of the workforce by a big healthcare franchise because of the misplaced priorities of profits before patients. Here I am, a highly educated Hispanic nurse who was mentoring Hispanic nursing students to promote more minorities in the profession when a major healthcare franchise decided I was a dirty Kleenex to be thrown away into the trash…. like my years of education, my life, my daughter’s life—meant nothing. I’m one of those minorities you talked about today and I was rendered useless by a doctor who never met me or heard my name. One less highly educated Hispanic nurse (and potential leader and mentor and teacher) in the workforce. The sad thing is, this tragedy is happening to more nurses all over the country every single day. Some have committed suicide from the trauma of losing everything for doing what they were taught in school to do.

Dr. Carmona emphasizes how badly we need more well educated minorities in the workforce—the question is, how is he going to protect the workforce in a right to work state where anyone can get fired for the color of their hair or skin? What will Carmona do to protect nurses from a doctor who waves a magic wand and decides to throw them in the trash like God waves his hand to calm a storm??? What I needed to hear today as a well- educated single Latina mom, voter, and nurse BACK ON WELFARE was that he was going to sit down at the table to figure out what can be done to keep it from happening again TO ANYMORE NURSES. That he would work WITH US to find solutions. What I HAD HOPED to hear today was that he cared about the preservation of the nursing workforce and that he would do what it took to make sure we could protect patients without having to be placed in the position of deciding whether to act in the best interests of the patient or our own.

Dr. Carmona made a couple of interesting points today. The first one was in reference to the useless fighting going on between political parties in the midst of catastrophe and how it’s accomplishing nothing. The same could be said for how both the disciplines of medicine and nursing interact with each other. The second point he made had to do with the Titanic. “The ship is sinking and we’re all worried about where the deck chairs are supposed to go”….or something like that—you get the point. Again, the same could be said about our healthcare system and nursing’s place in all the mess. Our profession, our scope, our ability to do the very things we are licensed and educated to do is like a big ship going down and yet we are busy writing position statements and having pretty conferences to talk about all the things that should be done instead of just getting down to the business of doing it.

I suspect if I had maybe 10 other nurses with me today— bedside nursing care nurses, I would have been heard and not waved off like a fly. But it’s moments like these that tell you where you stand in the big picture…and it seems I have a long way to go before I make it to Capitol Hill. When you can’t get your own state’s politicians to slow down, make eye contact, and “listen,” how on earth can you get Congress to care when you go there to testify?

Not all is lost. In my sluggishly slow journey to Capitol Hill I have met some great candidates who have done just that-–made the eye contact, the time to listen, and most importantly—showed they cared about the issues. While Carmona has clearly excelled in every way throughout his life, one cannot be good at “everything.” As a politician, staying safe in the middle is a very good way to lose the voters. At the beginning of the morning I eagerly put the Carmona bumper sticker in my purse and fastened a “Carmona” button to the lapel of my jacket. At the conclusion of his “talk” when everyone clamored into a line for photo-ops, handshakes, and hugs– I waved off the opportunity, unfastened the pin, tossing it back on the table along with the bumper sticker I “was” going to put on my SUV.  Bottom line: Nurses, and I’m not talking about the ones who have an RN after their name, sit in offices all day, and haven’t done a bed bath in like 20 years, need effective representation in the legislature and at the federal level…..this much was painfully clear today. Dr. Carmona is just not “the one” who will make nurses a priority on his agenda.

I’m not voting for Flake either—I grew tired of seeing his face on my television 500 times a day and hearing him say “you know me.” No I don’t, but I know enough to know I’m not voting for him. Where did Flake lose me? The high rotation of the campaign commercials were a big turnoff. It’s safe to say when you feel like throwing your laptop at your TV screen the vote’s been lost.

I’m left with the same three words that have been in my head since April 21, 2011…the day Banner Health forever changed the course of my life: “Si Se Puede.”

I have to believe in it. Or else…how does one keep moving forward toward accomplishing the dream….          

Behind Closed Doors: Case #6/Daily Distractions

Case Information: Graves v. Breakwood Health Services, Inc. (12/2009)

Summary: Nurses and Doctor fail to address IV infiltration, patient sustains injury

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe nursing practice. Thank You.

(Published with permission from nursefriendly.com)

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      It’s the first shift of three, and you are none too thrilled to be working. It’s Thanksgiving tomorrow and you had plans to spend it with your new husband in your new house, hosting your first holiday meal. Unfortunately one of the “core senior nurses” whined enough about not getting Thanksgiving off for the past two years and being the new grad you are—your holiday was the one sacrificed to that wonderful thing called “seniority.” Huddle time is over and all the nurses go to the desk in front of the nursing station to get their patient assignments for the day. You hold your breath because you’ve been warned by a friend that a frequent visitor to your unit “is baaaa-aaack” and you know by history that a “Mrs. Diaz admission” is a lengthy, needy and exhausting one—for the nursing staff. You look through each of your Kardex’s….slowly….one by one. So far so good, there’s only one left to look at so you take a deep breath and pull it out of the pile to get it over with. “God is clearly on a coffee break” you say to yourself when you realize Mrs. Diaz is yours not for just today….but for the next two shifts.

Sighing, you head toward the station you are assigned to, take report, and remain hopeful that you will have a good team of nurses and a decent day. Then you see her: The nurse who stole your holiday bliss, your first memories of a husband and wife during the holidays. She is going to be one of the nurses you’ll be working with today and even though it’s only 0800 “Miss Seniority” is already glowing, giggling, and huddled with her groupies talking recipes, matching outfits for the family, and flight arrangements. Your jaw tightens and there is a slow burn in your stomach. This is too much stimulation first thing in the morning.  Spotting the first work station away from the “main hub” you settle into your “happy place” for the day. A call light sounds overhead while you are deciding who to round on first….it’s Mrs. Diaz. You twirl your chair around to get up and go assess the first of her many “crises” of the day when you run right into “Miss Seniority.” She smiles sweetly and places a hand on your arm. Her voice is so sickingly sweet she could put you into a diabetic coma. “I just wanted to tell you how wonderful I think it is that you volunteered your Thanksgiving so I could be with my family.” With that, she pivots around and bounces down the hall into one of the patient’s rooms. You stand there, stunned, still looking at where her hand was on your arm, tension rising… “Did that just happen?” Right then a voice cries out “Nuuuuuuuuuurse!” You’re jolted back to the fact you are at work, and Mrs. Diaz’s voice is growing shriller by the minute. It’s time to set aside your frustration with “Miss Seniority” and focus. It’s going to be a long day. Taking a deep breath, you count to ten, grab your scope, and head into Mrs. Diaz’s room.

“Something is wrong with this IV!” She is angrily pointing at her left hand. Mrs. Diaz’s hair looks like a brown helmet pushed off to the left side of her head and she has circles around her eyes. “Did you sleep OK last night?” You ask. “No my hand was hurting all night and no one would come help me!” Mrs. Diaz dissolves into tears and you grab the box of Kleenex off of the bedside table and offer her some. “OK, let’s take a look and see what we can do to fix that.” Sitting in a chair next to the bed, you make eye contact with her. Speaking gently, you coax her into letting you touch the offensive IV site. Sure enough, the site is red and angry looking. There is no need to even attempt a flush to assess patency;  it would only cause more pain. Reaching into your pocket you pull out a couple of packets of sterile 2X2’s and kerlix. “ OK Mrs. Diaz let’s take that out and we’ll restart a new one in the other hand because you have to go down for your stress test today remember?” Through sobs and hiccups she nods in agreement and looks away so as not to see what you are about to do.  The catheter comes out easily, in one piece, and you quickly wrap the site while applying pressure (she is on Coumadin). “All done, it’s gone” you tell her. Mrs. Diaz slowly turns her head, opening one of the eyes she is squinting to look at the hand you are holding– and breathes a sigh of relief. She has a dose of Xanax due in thirty minutes and it would best for both of you if she were to get that dose before attempting another IV stick…..

It’s 1000 when the nuclear med lab calls you to get report on Mrs. Diaz before her Dobutamine stress test. The test time will be 1100 so you’ve got an hour to establish new IV access before she goes downstairs. Her call light has stopped ringing every ten minutes so the Xanax has clearly had its intended affect…now is the time to “aim and fire.” You want to get this done and over with not just because there is only an hour left before the test, but because you have been in her room at least 50 times which has made it very difficult to get rounds finished, beds changed, and baths done.  Your patience is wearing thin and you’re thinking it may be beneficial to take an early lunch to regroup and refocus. You find Mrs. Diaz lying in bed quietly, reading her bible. Perfect! The second IV goes in without a problem, an 18 no less! (Nuc Med is going to love you for that). It’s flushing and pulling back beautifully and it seems the little prayer you said before insertion worked a miracle! Mrs. Diaz didn’t jump, scream, or pull her arm away as she has during many of the previous hospitalizations. She is considered one of the more difficult patients to establish IV access on so you’re feeling like the day “may” be taking a turn for the better!

Fifteen minutes later, you are trying to get some charting done when Mrs. Diaz’s call light sounds overhead. You cringe.”Seriously?” “Again?” The aide comes to tell you Mrs. Diaz is crying because the new IV is hurting her badly. Acknowledging her, you thank the aide for advising you. “Enough” you think to yourself. “I can’t spend all day in there, I have other people, and I’ve got to get some work done.”   You do a little mental triage and decide to go give a bed bath to one of your “total care” patients when a colleague knocks on the door and peeks in: “The IV you just inserted seems to be causing pain.” You can’t stop what you’re doing at the moment and you feel a ball of tension rising in your throat. This can’t be happening again. A glance at the clock tells you the nuclear med people are going to be here any minute to pick up your favorite patient for the stress test. “Can you go assess it for me so I can finish up here?” You ask.  Your colleague agrees to go take a look and says she will report back to you. A few minutes later she returns looking a bit distressed. “Well, it flushed but there was obvious discomfort and a little leaking but the doctor and the techs were already there to get her and the doctor didn’t want to wait because they were behind. He said they would deal with it downstairs.” You nod in her direction and thank her for the help. Discomfort. Leaking. It sounds like another infiltration and Mrs. Diaz is a high risk patient because she has diabetes and a history for MRSA. When you get done providing your bed bath you call down to the nuclear med department to check on her but no one answers. You hope they have restarted another line before they began the procedure.

An hour and a half goes by and the tension you had been feeling all morning seems to have dissipated—more likely due to the fact you have been able to get all of your morning routine completed, your charting caught up, a snack, and a nice 30 minute break in the unit’s sleep room where there is a nice sound machine that blocks out all the hospital noise. As you’re heading back out to the floor one of your colleagues is holding up the phone informing you the nuclear med lab is on the line to give report before returning Mrs. Diaz to the floor.  The results were inconclusive because she was having a lot of pain throughout the procedure and her heart rate didn’t respond to the Dobutamine as they would have expected. They also report her right arm (the side with the new IV) appears to be twice as big as the other one and Mrs. Diaz has been inconsolable. The doctor apparently became frustrated and left mid procedure advising the nurses the test will need to be rescheduled.

You cordially thank the nurses downstairs and hang up the phone wondering if all the Dobutamine and saline flushes went right into her tissues causing extravasation. When she returns you note part of Mrs. Diaz’s arm looks like a pink football and she can’t lift it. The skin is warm, and tender to the touch. The nurses confirm that they did indeed push Dobutamine and saline through the site. “Great” you think to yourself. You immediately jump on the phone to the lead physician on the case and request he come take a look at the arm and advise you on what to do. More and more you are wondering to yourself if you should have gone back and checked the IV yourself before letting Mrs. Diaz leave and rescheduling the test until later if she needed another IV change. But you were frustrated with her, and needed a break. You are torn between both thoughts. You realize that anyway the situation is assessed you knew about the pain before she went downstairs, you decided to do something else rather than go see her, and now you are here in this moment with some obvious ugly looking skin damage with possible infection. This happened on your watch. As the shift enters into its last hours Mrs. Diaz develops a fever, nausea, and some unusual blisters around the site used for the test earlier in the day. Some of them are dark colored. Others look like second degree burns… they are getting bigger by the hour and Mrs. Diaz’s pain and anxiety is escalating. You call the lead physician again who comes upstairs to assess Mrs. Diaz before he leaves for the day. When he returns to the desk he pulls you aside to provide an update: “I believe we have a case of necrotizing fasciitis with Mrs. Diaz. I’m going to call in the Infection Disease specialist to come in from home so he can take a look and we can come up with a plan. In the meantime we must place her on contact precautions and limit the visitors into that room. I’ll go talk to your charge nurse.”   This is the first case of necrotizing fasciitis you have ever experienced and it could have been exciting…..except for the nagging and accusatory whispers in the back of your mind telling you: “This could have been prevented.”

The Real Thing

Shelvia Graves was admitted to Brookwood’s Digestive Disease Center on August 7, 2000. She had a long history for ulcerative colitis and was scheduled to have an upper and lower GI exam. Her health history was noted to be a complex one– including two prior colon surgeries, sinus problems, migraine headaches, iron deficiency anemia, and occasional blood transfusions. Prior to the studies Mrs. Graves had an IV inserted into the left hand. It was removed shortly thereafter due to an assessment of edema/swelling over the site. A new one was started in the right hand. Mrs. Grave’s testified: “(She) alleged that an infiltration occurred in her right hand and that she immediately began experiencing severe pain in her right hand, which caused her to cry.”(NAI, 2012) She (Graves) stated that “she told the nurses that the IV was inserted incorrectly and that it was causing her pain.”(NAI, 2012) Despite this, the nurses did not remove the IV. Dr. Champion, the physician who would be performing the procedure had come to see his patient prior to procedure so Mrs. Graves appealed to him by advising him of her concerns about the IV and the pain it was causing. Dr. Champion, concerned about already being backed up in his schedule of procedures responded to Mrs. Graves: “She would just have to endure it.”  The procedure took place as scheduled but afterward Mrs. Graves was alarmed when she noticed that her right arm and hand were significantly swollen–describing it as “looking like a boxing glove.” After being transported to PACU, Dr. Champion gave an order for warm compresses to be applied to the hand while reassuring the patient’s husband that the swelling would eventually subside. She was discharged from the surgicenter, without further intervention, shortly after that. Mrs. Graves would later bring suit against Brookwood accusing the nursing staff of being negligent. The initial finding was in favor of Brookwood, but the Graves’ appealed to the Supreme Court where it was later established via an expert physician witness that “assuming Graves’ patient history was accurate; he believed that the IV infiltration probably caused the injury.” (NAI, 2012)

Questions for Discussion:

1. Were there any examples of patient centered care in this case? If not, give some examples of where it could have been applied to this patient’s care.
2. Were there any examples of patient advocacy in this case? If not, give some examples of where it could have been applied
3. How was patient safety not upheld in this case? Be specific
4. Could this infiltration have progressed to a “never event?” How?
5. At what point(s) could nursing staff have advocated for Mrs. Graves, and why?
6. What mitigating factors could have prevented the nurses from removing the second IV as soon as the patient reported discomfort?
7. If the said IV was indeed infiltrated….how could that affect the patient’s overall procedure experience? Be specific.
8. How likely do you think this scenario is every day in the patient care setting? Why?
9. Perform a “pretend root cause analysis” to focus on the process that led to this event rather than focus on the “nurses and doctor” make a plan to prevent a similar event from happening

 Discussion

      It seems as though there is never enough time, or people, to help out in situations like these. That being said, we as nurses must be the ones to slow down the “people processing factory” and take back the tenets of our practice. I wrote about this case not only because I have seen IV complications happen, but because I know they happen everywhere, every second, in just about every healthcare facility across the country. Two terms we should understand and differentiate between when initiating IV therapy are “infiltration and extravasation.”  “Infiltration is defined as the inadvertent leakage of a nonvesicant solution into surrounding tissue, and extravasation is the inadvertent leakage of a vesicant solution into surrounding tissue”. (Dychter, 2012) IV complications are a universal problem regardless of the area you specialize in, and they should not be regarded as “minor incidents” as they can often progress to much bigger problems and poorer outcomes for the patient.  “Both infiltration and extravasation can have serious consequences including full-thickness skin loss and muscle and tendon necrosis. The patient may need surgical intervention resulting in large scars, experience limited function, or even require amputation. Another long-term effect is complex regional pain syndrome, a neurologic syndrome requiring long-term pain management”. (Dychter, 2012) Special care should be taken when working with pediatric, geriatric, and patients who have active diagnoses of dementia or Alzheimer’s—these individuals are at risk for not being able to effectively advocate for themselves.

Contrary to popular belief, there is no such thing as a leaky IV that is “working,” –or my favorite– “a positional IV” that you have to maneuver just right by pulling back the catheter, pushing it in further, or jiggling it left and right just to initiate a saline flush! There should not be a visible hole around the catheter with fluid coming out around the catheter. Nor should there be a dirty film of dried blood covering the IV site so that it is hiding the insertion site and the surrounding skin. All of the above lead to infiltrations, extravasations, and infections. Research points to “phlebitis” as the most frequent complication of IV therapy. Signs include redness, swelling, and tenderness. “Phlebitis  may occur at rates as high as 50% or even as high as 75% in patients with infectious diseases; however, the incidence rate in patients who do not have diabetes, burns, or a need for urgent catheter insertion is approximately 20%. A number of risk factors have been implicated in the development of phlebitis. Patients who are female or who have poor-quality peripheral veins, insertion in the lower extremity, or the presence of underlying medical conditions, including cancer and immunodeficiency, are at increased risk for phlebitis”. (Dychter, 2012)

When we make our “nursey-do” list our attention is naturally focused on those “big ticket items”: Our lunch breaks, the two new admissions on their way up, the Nitro drip that’s running dry in room 210, the increased runs of V-tach the guy in room 201 is having, the 90 year old who keeps trying to climb out of bed activating the bed alarm every five minutes, the antsy surgeon calling you into room 220 to help undo a dressing. In the midst of all that who’s thinking “I gotta replace that IV?” I know I wouldn’t be. As a remedy, I maintain a running list of things that *must* be addressed.  I check in regularly with my patients not just to let them know where they are on the list but to convey they haven’t been forgotten.  Checking in also gives me an opportunity to reassess the patient and “re-triage” my list if something happens that necessitates me fixing a problem I had earlier identified as not so urgent.

Patients know, and they will verbalize when an IV doesn’t look right, feel right, or when it’s been in “too long.” Don’t ignore or underestimate their ability to pick up on details or your interventions to remedy potential problems (like being receptive to their concerns). Your actions enhance a patient’s feelings of security and confidence in you as a nursing professional.  When I’m acting as a private patient advocate, it’s usually the first thing I pick out: gross looking IV’s that have been in, according to the family, “for days.” An IV related infection not only has an impact on patient care outcomes, but on healthcare related costs: “For each episode of infection, hospitalization is prolonged by 7 to 14 days, and survivors average an additional 24 days in the hospital. Estimates of the added cost of treatment range from $3,000 to $56,167.” (Dychter, 2012)

I hear you, and I get it—I really do: “I passed it on to the night shift because I was so busy and couldn’t get to it,” “I passed it on to the day shift because the patient was sleeping,” “Night shift doesn’t do anything but sleep so they can replace the IV,” “The day shift has more staff and more resources so they can do it.” Gotcha. Now, how many of those “passing the ball” scenarios will play out before the patient gets septic thrombophlebitis or contracts necrotizing fasciitis? At that point we as nurses become the “sharp end” of the error that has reached the patient. ” In an article written for the Journal of Nursing Law, Marc Green, PhD, posits that errors reaching the patient are often the product of  “automatic behavior” and “adaptability”: “Automatic behavior is an especially frequent cause of error….(as is) “inattentional blindness,” a phenomenon so pervasive that it occurs more than half of the time under some circumstances. Inattentional blindness is not caused by carelessness or stupidity. Rather, it is the natural result of two fundamental aspects of the human condition: limited mental attention and high adaptability. Adaptation, however, is a two-edged sword because it improves performance when circumstances are stable but can create errors when the situation changes.” (Green, 2004)

What’s an article about IV complications without a word or two about care plans? If you are doing them regularly, and a thorough physical assessment each shift– the IV site should be a pretty easy thing to spot as an “at risk for infection” nursing diagnosis.  Take a moment to think about how you would defend your practice in a court of law involving a patient who died of bacteremia secondary to MRSA from an infected IV site?  If it were you who picked up a patient for three days that had an IV in for 6 days and you did nothing (and documented nothing) to assess the site, clean the site, or change the site you’ve taken an awfully big gamble not just with your license, but with that patient’s life. “Increasingly, nurses are named as defendants in malpractice actions, many of which involve administration of IV fluids and medications. More than 2% of medical practice liability claims involve peripheral catheters, and claimants have been awarded up to $10 million per claim. Nurses who deliver IV therapy are subject to litigation for failure to monitor and assess the patient’s clinical status, prevent infection, use equipment properly, or protect the patient from avoidable injury. In the event of a claim, complete and accurate documentation is important for an effective legal defense”. (Dychter, 2012) Care plans are your justification (and best defense) for the care you provide patients. It’s the answer to the question you could be asked on the stand in a court of law: “Why did you perform this action versus something else?” If you make care plans a habitual part of the patient care day you’re more likely to embody a higher sense of awareness and accountability to basic nursing standards of care while engaging in “best practice.” Doellman, BSN, places further emphasis on the risk management involved with IV complications: “Clinicians should be prepared to act promptly when an event occurs. Thorough incident documentation helps determine whether infusion care meets the standard of practice and is a keystone to medicolegal defense.” (Doellman, 2009)

 

Now, a special shout out to the nurses we all know and love….the “regulars” who can be heard crying out  “I’m not good at putting in IV’s” or “I hate putting in IV’s!” Newsflash: You won’t get any better avoiding it, it isn’t everyone’s favorite activity, and you’re far more likely to irritate and burden your colleagues by making the rounds asking (or begging) anyone who will listen to do it for you. Paging the PICC nurses 100 times in a row also falls under the “irritate category!”  Do you think these nurses were born with a magic gene for stellar IV skills? They had to start someplace before becoming vascular superstars they are today. They also—have a day to get through.  Have you heard the term “man card?” Take your “nurse card” back and try to establish the line before you deem the situation hopeless. Date your IV’s. Be aware of how long your patients’ IV’s have been in. According to the standards of care for infusion nursing it’s best not to change an IV prior to 72 hours if you can help it, but an IV can be left in as long as 96 hours if necessary. Be wary though, exceeding 96 hours to promote comfort for the patient may well yield other problems that will be much more costly for both the patient and the hospital.

Finally—and most importantly: listen to your patient. One could argue that the real life case presented in this article demonstrated a lack of patient advocacy on behalf of the nurses and a failure by the physician to keep the patient at the “center of care.”   Even if the line has just been placed—if it hurts, take it out. If your patient is in pain, it is your job to address it no matter what the source of the pain is or what time the procedure is scheduled for. There is nothing hi- tech about this—it’s all hi- thinking and hi- touch nursing….. So press the “stop” button in the people processing factory, take a breath, and remember where we are as nurses—we are the last barrier of safety between the healthcare system and the patient. Without the protection and vigilance of a nurse… we ourselves become the sharp end that hurts the patient.

References

Doellman, D. H.-G.-O. (2009, July/August). Infiltration and Extravasation: Update on Prevention and Management. Journal of Infusion Nursing, 32(4), 203-211. doi:doi: 10.1097/NAN.0b013e3181aac042

Dychter, S. G. (2012, March/April). Intravenous Therapy: A Review of Complications and Economic Considerations of Peripheral Access. Journal of Infusion Nursing, 35(2), 84-91. doi:DOI: 10.1097/NAN.0b013e31824237ce

Green, M. (2004). Nursing Error and Human Nature. Journal of Nursing Law, 9, 37-44. Retrieved September 30, 2012, from http://www.visualexpert.com/Resources/nursingerror.html

Hughes, R. (2008). Nurses at the Sharp End of Patient Care. In Patient Safety and Quality: an Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality. Retrieved September 30, 2012, from http://www.ncbi.nlm.nih.gov/books/NBK2672/

NAI. (n.d.). Were nurses responsible for injury from infiltrating IV? Retrieved September 30, 2012, from The Free Library: http://www.thefreelibrary.com/Were nurses responsible for injury from infiltrating IV?-a0221907926

Book Notes: “A new and unexpected fear.”

     …Early into the weeks of volunteering I have noticed something about myself. I’m terrified. As I get ready in the morning to go on my assignment I feel fear that is like barbed wire poking the outside of my lungs on the edge of each breath….. It’s only a few hours at a time, no biggie really, but when Im there I find myself standing in the corner of the treatment areas wishing I could somehow still “do this” but be part of the wall at the same time…. Invisible. Unrecognized– Like the air we breathe. Oh yes, breathing—I’m scared of that too. Scared of moving, scared of talking, scared of making eye contact with anyone, and definitely scared of touching anyone or anything. I think my director noticed that today because she pushed me right in as much as she could. A lot of times I have to talk myself down out of the tree. After all, my role is one of “take direction and do.” No critical thinking involved, no decision making, just being a part of the team and doing the patient care aspect. Perfect. Even that little bit is difficult right now and I am unsure if it is because I have been out of practice for two years, because of the enormity of what has happened and the battle I fought to keep my license….or the knowledge that all it takes is a simple case management consult, the act of advocacy, a nursing intervention nurses do every day –to ruin you as both a nurse and a person.

I wonder sometimes if this is how inmates feel when they are released from jail or prison. Do they feel scared about moving around in the community? Do they feel anxious about trying to become productive members of society again? Do they dread the job interviews when they will be asked about their criminal history? These are just things I think about. Every day and every night. I’ve never claimed to be the perfect nurse, without faults, and I have made mistakes that any other nurse could make in his/her career as part of the learning and growth that goes with what we do. But I have begun to equate this case management consult, the one specifically requested by my patient, to a criminal act. A sense of shame has grown with that change in my thought process. Perhaps this is the fallout that comes with being a corporate whistleblower in the healthcare industry. Maybe this is what comes with the package and what we aren’t told about in nursing school.

Adhering to oath and code carry with them dangerous, life altering risks and consequences, some from which you will never really recover. They change you so profoundly; you are never the same person or the same practitioner again. I was excited about volunteering…still am. But now I am also scared of it. I am scared of nursing. Though I feel like I am this epic fail of a nurse, I have never hurt a patient, never had a sentinel event in my career. I’m damn proud of that. I constantly have to remind myself of this accomplishment because I worked hard to keep it that way. I’m going to give this volunteer thing some time because I think it’s something my soul needs to work through. If anything, I can do the soup kitchen full time—it’s still helping people. When you love something as much as I love nursing and giving to others,  and when it is such a big part of your own spirit, I think it’s important to do whatever work necessary to wait it out….decipher whether feelings are a temporary reaction to a new experience….When I am actually doing hands on care and “getting into it” the fear and anxiety seem to melt away and I feel like the “real me” begins to come out of hiding– rising to the surface of life– I’m smiling, conversating, breathing freely, I’m right there in the moment, like it’s all second nature….For now that’s a beacon, a sign of hope that I’m still in here somewhere….that the nurse is still alive.