Jon and Kate: I think I'll medicate!

Call me silly, but I'm always surprised when highly predictable events happen. Take the high-profile dissolution of Jon and Kate Gosselin's marriage.

Under circumstances that can best be described as childbearing Yahtzee, a young couple in rural Pennsylvania manage to add six-of-a-kind to the deuce they rolled in the first round of play. Shortly thereafter, they score a reality TV series, adding producers, cameramen, photographers, hired help, speaking engagements, investment portfolios, and book tours to the primary task of raising eight humans, six of whom--unfortunately and largely without precedent--share the same developmental stage.

She thrives, leaving the stay-at-home-mom-who-happens-to-drive-a-church-bus image behind and morphing into someone who might be credibly cast on "Real Housewives of Punxsutawney." He begins to resemble Jim Carey in "The Truman Show." The marriage crumbles. Who knew?

Marriage in the U.S. doesn't have great odds to begin with, and marriages with high-order multiples have higher failure rates than others. But like Captain Renault in Casablanca, we're shocked, shocked to find that gambling is going on in here!

The denouement of Jon and Kate has left me thinking about medication use, a topic that could reasonably be expected to arise in an upcoming episode. So, in the short window of clarity that followed the "ah-ha" moment when I learned Jon and Kate ain't great, I jotted down eight things about medication safety that you, too, probably knew all along. (Apparently, we should be shocked, shocked to find that gambling has been going on here!)

1. If you routinely identify patients using 2 distinct identifiers and engage them in the care that's about to occur, you're less likely to give a patient the wrong medicine, conduct the wrong test, or perform the wrong surgery.

2. If you make drug information available to clinicians on the front line (preferably in a mode that's as easy-to-use as an iPhone, not a dogged-eared text from an earlier century), the clinician administering drugs will be able to become familiar with, and actually double check, unfamiliar drugs and doses before administering them.

3. If you say "fifty" (without saying "five-zero") over the telephone, you're likely to be heard to say "fifteen." "I'll be there in 15 (or 50?) minutes" is not as much of a problem as, "Give her 15 (or 50?) units of insulin." Break multiple digit numbers into their simplest form, say and spell drug names, and read back and verify high-stakes information that's transmitted verbally.

4. 1400 commonly used drugs look like or sound like another one. These similarities regularly cause competent people to select an unintended drug from a computerized pick-list or mis-hear a drug as its sound-alike cousin. If you include the purpose for the drug on all orders or written prescriptions, this information allows another knowledgeable professional (like a pharmacist or nurse) to detect and derail a look-alike, sound-alike (LASA) error since few members of LASA drug name pairs are used for the same purpose.

5. If balsamic vinegar and olive oil come in similar containers, it's easy to kill a quesadilla. How drugs are stored at work matters, too.

6. If something can be attached to something else, someone will attach it. Good for tinker toys, Legos, and jigsaw puzzles. Bad for oral medications in parenteral syringes and pressurized B/P tubing connections that are compatible with IV lines. If you can't put diesel fuel into your gas tank by mistake, why don't we have similar safeguards in place at work?

7. If the lighting is bad in a restaurant, you have trouble reading the menu. If the lighting is bad over automated drug dispensing cabinets, your front line is going to have trouble reading the labels of the drugs they remove from them.

8. The average age of a nurse is around 50 years old. Most drugs that are given today were boiling in a cauldron somewhere when we took our boards. If you define how risks associated with high alert medications and LASA drugs are managed in individual care settings within your organization and teach these strategies to nurses (and others who handle drugs), you will prevent mistakes that have been made elsewhere from occurring where you work.

I hope you find these 8 to celebrate, agitate, and advocate, eight things that will help you take care when you medicate!

Grand Rounds: More than good stories found

One of the things I like best about Grand Rounds is that I find inspiration to help bring my hodge-podge of loose thoughts and impressions together.

Healthcare reformers and activists have begun to focus on the $20 billion American Recovery and Reinvestment funds that--God-willing-and-the-creek-don't-rise--will make IT in healthcare "meaningful." The National Committee on Vital and Health Statistics' Report of Hearing on "Meaningful Use" of Health Information Technology captures multi-stakeholder concerns well. It's a worthwhile read about the realities we face in harnessing strong IT solutions to transform healthcare efficiency and outcomes.

I jumped at the chance to talk about meaningful use last week, both here and over at On Your Meds, the Medscape medication safety blog I write. Although I'm techy by nature, it doesn't take a specialist to see that the current state of IT often makes front line clinical people tie the horse to the Edsel's bumper to advance a care goal. (If you missed Gina's story a few weeks back, it's worth a read to sample just a few of the unintended consequences front line clinicians face when e-systems fail to communicate.) So I posted call-to-action pieces about meaningful use, advocating for IT outputs that would make patient data central and help get front line clinicians out of the manure.

Then I started reading what cutting edge e-patient advocates and health 2.0 innovators were saying about what "meaningful use" might really mean. E-patient Dave's remarkable story is one that has drawn attention to health IT's intention-outcome mismatch. The power of high-end patient involvement left me feeling that my "make it work for those on the line" approach was like suggesting we replace "Mr. Ed" with "Rachel Alexandra" on the bumper.

But today at Grand Rounds, I stumbled across the story of a man, and his family, movingly told through the fresh eyes of a soon-to-be nurse in Brain Death, Part 3. The patient and family in the story, especially when contrasted with e-patient Dave, show the vast continuum of abilities and circumstances of people in our care.

We most certainly need to get the horses off of the bumpers. But we also need to be certain that we advocate for models of care--which are ultimately what IT solutions support--that allow all kinds of horses to make it around the track.

Want a good idea? Download a free copy of Good Book.

Creating a place on this blog for Flo & Bo's "favorites" is on my "to do" list. Obviously, that's not something that got done this weekend or I wouldn't be force-posting at this late hour.

One of the non-linear sources of inspiration that will surely make the list of favorites when I get them catalogued is Slate magazine's weekly podcast "Gabfest." I say "non-linear" because there is absolutely nothing offered on the weekly Gabfests that has anything to do with "patients" or "safety" (unless one of the hosts has a splinter). But they nevertheless manage to inspire good thoughts about wide-ranging topics.

Here's the take-away: the folks on the Gabfest are allowing fans to download David Plotz' new book, "Good Book," free (until this Friday, 5/29). Use this link to find the details: www.audible.com/goodbook.

I'm already a member of Audible.com, but I had my son, who is not, download the book yesterday. You don't have to enroll in any trial subscription or provide a credit card number. Just register on the Audible.com site, then download to itunes or MP3.

I haven't read Plotz' Good Book yet, but I listened to several chapters while gardening today. I was laughing out loud! I hope you'll enjoy it, and listen along with me this week.

Thanks David, Slate, and Audible.com!

All riding is therapeutic riding

used with permission

When my daughter was eleven, I sent her to stay with her grandmother in rural New Mexico for a month, as the brewing storm in our relationship seemed certain to explode in the long, hot, empty Georgia summer days. When she returned, our suburban family included a devoted horse enthusiast, and none of us have ever been--or really wanted to be--the same.

My daughter is deaf, and she uses a cochlear implant to hear. If you're not familiar with what that means in functional terms, it's this: my daughter hears, but not always or well. The precision, quality, and reliability of the sounds received are not the same as what a person with normal hearing experiences. Distance, background noise, and lack of contextual cues bother people with cochlear implants more than they bother others. Toilets flushing are easy to discern. Speaking voices are hard. Giddy-up!

Early-on, I remember spending a fair amount of time and energy at Radio Shack, purchasing, then returning, an array of electronic widgets that might help the trainer's voice reach across the dusty, windy arena to further "level the playing field" for my daughter. But the most vivid memory I have from that era is when the trainer, now a dear friend, called me to say, "I know you know your daughter doesn't hear well. But she doesn't listen either."

I knew that.

I think there are times when we all know things like that. People who work in quality and patient safety are learning that it's impractical to rely solely on linear approaches to improve outcomes in a highly complex system, like healthcare (especially if you're looking for changes that are both safe and satisfying). Just ask anyone who is still hungry after being fed their Core Measure Happy Meal.

Therapeutic riding programs are often used to bring horses and people who have profound physical, developmental, and emotional disabilities together, with results that often exceed the primary objective for showing up in the first place. My daughter never enrolled in a riding program that claimed any particular expertise in facilitating the needs of hearing-impaired people. But hang around horses and the people who love them for any sustained amount of time, and you'll likely conclude what I have: All riding is therapeutic riding. How easy it is to see what's broken is what distinguishes riders with special needs from others.

I didn't go to the National Patient Safety Foundation Congress this week. But I followed tweets from people who did, giving me the opportunity to be pleased in real-time when I saw that teamwork and relationship-building, as vehicles to enhance outcomes, were championed. We need results that exceed the articulated primary objective, results that, as equine activities model, can be predicted to come through relationships centered around high-stakes activities and hard work. Sounds like healthcare!

Giddy-up!

Healthcare Technology News: Grand Rounds

Healthcare Technology News: Grand Rounds

Health care reform at Grand Rounds

Grand Rounds is hosted this week at Healthcare Technology News with a special edition focusing on Health Care Reform. Interesting reads about what ails--and what may fix healthcare--from a wide range of perspectives make a trip over to the tech blog today particularly worthwhile.

Florence dot com, busy contemplating a move to Wordpress didn't go to Grand Rounds this week, but her sister blog over at Medscape did. (At On Your Meds, the topic Flo & Bo took on--how to spend $20 billion for health IT in a meaningful fashion--also came up, but no mention of bodily fluids occurred during the making of that post!)

I think the role of the consumer in healthcare is one worth exploring, and Grand Rounds is a great place for front line health care providers to hear directly from them. Seeing people at their most vulnerable, and benchmarking patients by the capabilities of those who are unlikely to be effective self-advocates is yet another huge disadvantage of our "in sickness and in more sickness" model of care. People who bring the same sensibilities to managing healthcare they bring to other high-stakes endeavors should help set the bar for patient engagement, with default strategies made to protect patients when they cannot assume these functions. (If you've missed how I once saved myself from a significant warfarin overdose, you can find it here.)

My parents, retired teachers living in central Florida, have online access to their medical records via a portal in their physician's EMR. The system also churns out a printed and up-to-date medication list following each visit. In the land of IT possibilities, these are modest things to be enthused about, yet they represent cutting edge patient involvement in health records.

Enjoy Grand Rounds today! (Judge Judy will not be attending, no need to roll up your pant legs.)

Meaningful use: Don't pee on my leg and tell me its raining

Standardizing and automating processes within a complex system makes the system more reliable, that is, more likely to produce an expected outcome. This is a core principle of system design although one infrequently taught to front line healthcare professionals, most of whom came-of-age in an intention-based ethic.

If Mr. Rogers were explaining what it means to come from a culture of intention , he'd say, "Can you say, 'The Five Rights of Medication Administration?' or 'Hippocratic Oath,' boys and girls?" But I'm not channeling Mr. Rogers here. This is a Judge Judy day.

Judy Sheindlin, you may recall, is the TV judge and author known for her sharp-tongued assessment and analysis of problems, most of which arise from choices made by imperfect humans and result in less-than-desirable outcomes. Judge Judy pulls from a strong personal moral center, but her opinions are informed by years as a family court prosecutor in New York City.

So what advice might Judge Judy offer to stakeholders who are about to get $20 billion dollars from the American Recovery and Reinvestment Act of 2009 to develop IT solutions that have meaningful use? I'm thinking it should start with, "Don't blow it!" and include a lot of input from front line clinicians.

To date, efforts to automate healthcare processes in clinical settings have produced, on a good day, variable results, especially when compared to what others (like Walmart, Chili's, AirTran, and hell, even Thrifty Car Rental) have achieved. This doesn't mean that automation doesn't work. It means that automation, like every other human endeavor, will rarely produce a desirable outcome spontaneously. (Or as my dad would say: "Fail to plan, plan to fail.")

Few, if any, health IT solutions in the public domain today were built on a strong patient-centric scaffolding, one that saw creation of a static stream of data to and from front line clinicians as a key objective. IT vendors have produced many satisfactory products and solutions. But their wares evolved in response to a market demand for piece-meal solutions, many arising in a reactionary fashion to address narrowly defined needs or mandates. We're now trying to satisfy a champagne appetite for high-stakes patient information that's been built on a beer pocketbook.

Making the patient the center of IT endeavors has the potential to make patient data the default output. And patient information is what professionals closest to the secretions need most to produce reliable outcomes: current medication histories; real-time medication profiles; provider orders; lab results; alarms signaling that an at-risk-to-fall patient has left the bed; that pharmacy-review of medication orders has occured; that an off-service test has been scheduled; that a patient is allergic to this food but likes that one; that an infusion is complete; DNR status; the list goes on.

Today's healthcare IT solutions are like puzzle pieces, with inter-operability specifications (enabling pieces to interlock with one another) in their infancy. Absence of shared platforms & standards may confer a competitive advantage to vendors in an unregulated marketplace, but it's the practical reason why your lab computer system often doesn't "talk" to your pharmacy computer and why patients admitted for community acquired pneumonia may receive a double dose of antibiotics when the ER's system doesn't "talk" to the inpatient system (an outcome, by the way, that standard quality reporting doesn't capture or penalize, but one that's not good for patients, not good for pocketbooks, and one that wouldn't be endemic with more robust communication systems.)

Front line clinicians often aren't enthused by the net effects of healthcare IT, and it's not because they don't recognize and enjoy the benefits of technology while grocery shopping, booking a vacation, or downloading music. But when patchy automation increases complexity and decreases efficiency--outcomes opposite those that normally found with tech-mediated solutions--don't blame the victims for not loving what torments them. Or, as Judge Judy would say, "Don't pee on my leg and tell me it's raining."

With $20 billion and a mandate to create IT solutions that result in meaningful use, maybe success can be measured by the whether the front line wears dry pants.

Change of Shift reflections

The nursing blog carnival Change of Shift is up this morning at Emergiblog, with links to posts that will inspire! There's some sort of post-Nurses Week, Trek-y thing going on over there that made me smile.

My favorite part of Nurses Week was cycling to Flo & Bo's Nurses Week playlist with my YMCA Group Cycling compatriots, most of whom had a nurse to honor. The warm-up began with Julie Andrews singing, "Just a Spoonful of Sugar" (which really freaked out the younger folks and caused non-cyclers to pop into the studio to assess the situation). But "Live and Let Die" and "Every Breath You Take" turned out to be surprisingly meaningful tributes to nursing care. Our talented leader, the daughter of a nurse, added Pink Floyd's "Comfortably Numb" to the list, a song which will definitely make the 2010 roster. (Warning: The current playlist made for a butt-kicking ride, and caused me to consider whether CPR would become part of Nurses Week celebrations at the Y.)

Flo & Bo are going to take a turn hosting Change of Shift in June, and I'm beginning to reflect on a theme. Current contenders include:

• What's Wrong with the Five Rights: System problems that prevent us from doing our best work. (My favorite involves a med-surg unit where the mean patient age was 82, the most common discharge site was a nursing home, and the most useless nursing activity involved going to Walmart on the evening shift to purchase adult diapers because materials management personnel had left for the day before unloading supplies.)
• Widgets We Love'd Love to Have: Technology solutions that make--or could make--your life (real or imagined) better. With so much twittering about stimulus funds and health IT solutions, nurses might want to share how practical, tech-medicated solutions could improve work-flow. Gena's CodeBlog post about a tough day in the ICU inspired this line of thinking.
• All Riding is Therapeutic Riding: Experiences and inspirations that make it easier to be a human.

Leave a comment here if you want to help select a theme. Here's my vote for "All Riding is Therapeutic Riding" from my May garden in Georgia:

Happy Birthday, Miss Nightingale!

The name "Florence Nightingale" often makes a post-World War II "nurse-as-doctor's-helper" image spring to mind. But Nightingale, born in 1820, was a well-connected, highly political person who founded modern nursing using epidemiological principles, marrying her cutting-edge knowledge of science with the practical experience she amassed providing hands-on care.

To celebrate Flo's birthday--and send a final salute to nurses during Nurses Week 2009--here are few "then and now" reflections:

In 1859, ten years after beginning her career as a nurse Florence Nightingale publishes Notes on Nursing: What it is and What it is Not.

In 2009, President Barack Obama appoints Mary Wakefield, RN, PhD to serve as the Chief of the Health Resources and Services Administration (HRSA), an agency overseeing programs that bring health care to uninsured people, particularly in underserved areas of the country. Wakefield's agency will administer $2.5 billion to invest in health care infrastructure and train health care professionals.

Bo says, "Way to go!"

In 1860, Nightingale writes this about noise:

"Unnecessary noise, or noise that creates an expectation in the mind, is that which hurts a patient."

Today, YouTube (and Ameriquest) document the consequences of unnecessary noise in healthcare settings:



Bo says, "ROFLMAO." (Sorry, Flo.)

In 1860, Nightingale's Notes on Nursing says this about food,

"Every careful observer of the sick will agree in this that thousands of patients are annually starved in the midst of plenty."

A century and a half later, the U.S. Department of Agriculture reports 38 million people in our nation – 13.9 million of them children – live in households that suffer from hunger or live on the edge of hunger. The Food Research and Action Center provides education to a citzenry with increasing BMIs: Hunger and Obesity? Making the Connections.

Bo says, "Any program that removes recess from the school day to add more time for classroom instruction should be called, No Child Left Without a Big Behind."

In 1860, Nightingale challenges the conventional wisdom of her time saying,

"'What can't be cured, must be endured' is the very worst and most dangerous maxim for a nurse which was ever made."

In 2004, the association between patient outcomes, nursing care, and the conditions under which nursing is practiced is re-visited in a seminal IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses. "Coulda, shoulda, woulda" models of practice may join other cast-offs (like caps and bad shoes) as evidenced-based care, researched best practices, and patient-centric designs take hold.

Bo says, "Happy Birthday, Miss Nightingale!"

(If you don't want to wait until next year for more of Flo & Bo's wisdom, subscribe to this blog and follow along on Twitter!)

While it's sometimes tempting to eat the young, here's a better recipe

Welcome to Flo & Bo's continuing series on nursing sensibilities. This week hundreds of colleges in the US are graduating students, celebrations that herald the arrival of a new wave of graduate nurses, pharmacists, PAs, and therapists who will soon join the ranks of seasoned professionals providing healthcare. Welcome! We surely need you.

A month or so ago NPR ran a story in which a woman answered questions from her young son about how she met his father. I hope you'll have time to click on the link and listen to the 3 minute story from NPR's Story Corps.

If you can't, here's the part that spoke to me: This storyteller's mother had died when she was 7, and she was on her own by age 16. As the mother interacts with her son, she doesn't hesitate to answer his probing questions, but takes care at the beginning of their conversation to say, "So, what I did and what you get to do are going to be two different things because ...."

At this point in the dialogue her son abruptly, but confidently, interrupts her and finishes her sentence by saying, "I always have somebody looking out for me. That's you, dad, and pretty much everybody else in our family."

I could have used this story on Mother's Day. But I think the message transcends parenting, and speaks more to what people in the Judeo-Christian tradition call original sin, acting on the urge to subject the next generation to trials and tribulations that caused pain, dysfunction, and disorder in previous ones.

If you're about to orient new graduates, you'll likely use some sort of skills checklist and an evaluation process to document their mastery of core skills and validate emerging competencies. These are important tools, but the mother-son conversation illustrates another, equally important, measure of successful transition. It happens when the next generation can speak confidently of what's to come, without having to walk the same painful path that you did.

Resisting the urge to "eat the young" is the right thing to do. But today I'm also going to make a business case for why you should go out of your way to include novices, facilitating their transition to professional practice, and advocating for their voices to be heard.

Just two months ago, a Business Roundtable Health Care Value Comparability Study commissioned by CEO's of leading companies in the U.S., described a 23 percent “value gap” in the cost and performance of healthcare in the U.S. when compared to five leading economic competitors, all industrial nations. Foremost among the criticisms of the current system offered in the report?

"......basic practices untouched by the productivity revolution that has transformed every other sector of the economy." - Ivan Seidenberg, Chairman and CEO, Verizon Communications

Each and every day, seasoned healthcare professionals bring unmatched clinical expertise to mind-boggling, soul-wrenching problems, expertise that drives innovation, outcomes, and miracles (something I experience first-hand every time I speak to my pre-lingually deaf, cochlear-implant-using daughter by cellphone.) And I thank you.

But, having finessed high-tech miracles using antiquated infrastructure for so many years, seasoned professionals may no longer recognize the gap between what we find acceptable when shopping at the AT&T store and what we find acceptable when we go to work.

The "digital natives" about to join your ranks will see this gap. They're going to ask why a second registered nurse is paid to re-enter data previously entered by another registered nurse. (And, "The ER's system doesn't 'talk' to ours" won't satisfy them.) They'll ask why 17 distinct, but clinically irrelevant, variants of a penicillin allergy can't be purged from admission assessment documents containing over 100 distinct patient queries. They'll understand the inherent safety problems that arise when a pharmacy's computer system doesn't interface with those used to display laboratory results (and they probably won't think "tubing" or "faxing" a hand-written slip to compensate for electronic snafus is an acceptable way to communicate high-consequence data). They'll wonder why a bar-code scanner isn't attached to every anesthesia machine and why checking a price tag at Target is easier than checking a high-alert drug at work.

Digital natives will adapt their social media skills (like facebooking and twittering) and harness modalities (like iPhone apps and blogs) to communicate deficits, network, and help redefine best practices, allowing the productivity revolution that has transformed every other sector of the economy to illuminate the corridors of healthcare.

Welcome, sunshine! We need you more than we know.

A touching tribute

Happy Mother's Day! It's a good day to talk about feelings, continuing Flo & Bo's series of daily posts honoring nursing sensibilities.

I became a nurse because I was fascinated with birth, the highly complex process that allows one person to emerge from the body of another. On Mother's Day, we celebrate important relationships that happen in the aftermath of birth, few as straightforward as the creative act itself.

I come from straight-talking women, and I'm fortunate to be my mother's daughter. My maternal grandmother understood complicated things about birth and birth-control, offering on-point observations that included "a drop's as good as a cupful." (Country-woman wisdom that carried a microbiologist's understanding of conception.) But my grandmother's knowledge didn't necessarily inform her personal situation: I'm descended from her 7th child, a change-of-life baby who came along when my grandmother longed to have a driver's license, not another baby.

She managed to get both.

My mother had something of an "auto-pilot" upbringing, which was probably characteristic of the way children born in 1935 and trailing their next-oldest sibling by a decade were raised. She emerged with a concrete, sequential outlook, a way of thinking and organizing data that is best evidenced by the neatly written, color-coded files and lesson plans she maintained throughout her long, distinguished career as a public school teacher in Pennsylvania. In a word, my mother is reliable.

"Auto-pilot" was not the style of parenting my mother used when it was time to raise her children, though. In the house where I grew up, if someone said they'd pick you up following an after-school activity, they did. If you had a doctor's appointment, someone took you to the doctor. When the phone rang, someone answered it.

My mother isn't dogmatic. She doesn't do things for the sake of doing them nor does she do everything herself. Not everything makes it onto my mother's "to do" list. But when it makes the list, it gets done. (She once wrote, "relax, have fun in sun" on the list of things my husband and I were assigned to do in the days preceding our wedding, an entry that we--not fully understanding the mind of a concrete, sequential person--found both humorous and somewhat disturbing. Twenty-two years later, my mother stands by her decision to put "have fun in sun" on the list.)

Thank you for letting me grow up knowing what reliable looks like, Mom! I wouldn't be "the nurse with an engineer's mind" that I am today without you!

Bo with her highly reliable parents.

Something smells good

Welcome back to Florence dot com where Flo & Bo are celebrating nursing sensibilities all week. Here's a link to a free Cinnabon, a sweet gift brought to you through a special program recognizing nurses, the DAISY Foundation. (I told you something smelled good here!)

DAISY Foundation activities promote eradication of auto-immune diseases while recognizing nurses for outstanding care that was given to a vibrant young man named Patrick Barnes. The foundation's DAISY Awards continue to recognize excellence, saluting individual nurses whose care continues to make a difference in the lives of patients every day. And the nod to Patrick's love of Cinnabons makes the award smell incredible!

This program appeals to Flo & Bo's sensibilities because it recognizes that system-level solutions make it possible for nurses to foster meaningful outcomes, like healing, peace, and dignity. DAISY Foundation activities also support excellence in nurse recruitment and retention, evidenced based care, and nursing research.

Things are beginning to smell good in my garden, too. Not Cinnabon good, but fresh-cut grass and Confederate jasmine good. The daisies aren't blooming here yet, but you can see a few Becky Daisies, a Georgia native plant, on the left in the picture below, where I captured the season's first daylily yesterday.

Here's a shot of another Georgia native plant, Oakleaf Hydrangea (Hydrangea quercifolia) in my backyard that's going to be smashing by next week:

I hope you'll check back to see the hydrangeas and learn how tapping the knowledge of front line workers (the natives in the healthcare garden) makes patient safety initiatives bloom. Subscribe to new posts on the right-hand side of this page and SafetyNurse on Twitter to catch new posts and quick-hits about sensible things that make patients safe.

Do you see what I see?

Everybody likes a good story, and I hope you'll enjoy one about a near-miss medication misadventure as the celebration of nurses and nursing sensibilities continues during Nurses Week 2009. I like this one because it shows that responsive nursing care remains vitally important to achieving safe and accurate medication use. No HIPAA violations will occur here, because this is my story.

I hope you'll be able to see what I see! And if you like reading this story and analyzing the case, ISMP's Nurse Advise-ERR, a free electronic newsletter, can arrive in your e-mail inbox, giving you access to more error reports and ways to reduce risk. Your free subscription can be activated by registering here.

Several years ago I sought care in my local ER for unrelenting chest pain of about 3 days duration and was diagnosed with bilateral pulmonary emboli. (I would strongly discourage others from waiting for three days to have chest pain evaluated, but in keeping with today's theme, I'll just say that hindsight is 20/20.)

In any event, I was fortunate to have had slow-onset pulmonary micro-emboli, the kind that tend to resolve with anti-coagulation, leaving sufferers in good shape on the back side. So from Sunday evening until Friday morning, I became the lowest maintenance inpatient on a busy medical-surgical unit: I had IV access for about 24 hours, received sub-cutaneous enoxaparin (Lovenox) each day, had daily labs and took a warfarin tablet each evening. The hospital had electronic medication administration records (MARs) and bedside bar-code scanning matched me to my electronic MAR and to the medications ordered and dispensed for me.

You should also know that as a L&D nurse, my knowledge of warfarin therapy was relatively limited. By Day 2, I figured out that I was unlikely to die as result of this particular embolitic event (assuming the pulmonologist's statistics were to be believed). And, once the chest pain resolved, I spent most of the week connected to the hospital's wifi catching up on homework. (Being midway through a master's degree, I took survival of an embolitic event as a sure sign that I should finish school.)

Warfarin teaching came to me by way of the nursing staff. I understood the "go home" INR number to be 2 and was pleased on Thursday morning to know that my number was 1.8, close enough to therapeutic that one more pill and one more night in the hospital would likely buy me discharge home.

On Thursday evening, the nurse caring for me--and the computer work station and med cart she pushed--arrived as expected. My armband was scanned, the med was scanned. "Tonight," she said brightly, "You're going to get 2 pills instead of one." "Really?" I said. "Yes," she replied, "one 10 mg and one 7.5 mg."

I reflected. Something about the cheerful announcement made my hard-drive blink. (My personal hard-drive, not the one with my homework flickering on the screen.) But I had no concrete facts at hand. Having been thankful to survive the scary ordeal, I had been a relatively passive patient up until this point. In fact, I didn't even know what my daily dose of warfarin had been.

So I said, "I don't know much about anti-coagulation, but I have a question. Do you usually give someone whose INR is almost therapeutic a big dose of warfarin to push them farther into the range?" My nurse paused. "No," she said. "Do you mind checking?" I asked. "No, I don't mind. No problem. Glad to do that."

When she returned, she told me, "You doctor wants you to have just one: the 7.5 mg tablet," ending my close call with a warfarin overdose.

Professionals who work in a complex system, especially one that crosses disciplines, can usually see risk points (and opportunities for improvement) in their own sphere of influence.




When complex systems of care are analyzed, those closest to the patient are said to be at the "sharp-end." So if you're a nurse or other provider who touches patients, you're there. And when an error occurs, what went wrong at the sharp-end is relatively easy to uncover.

How to prevent reocurrence is more important than who made the biggest mistake. So I encourage you to look at the big picture, focusing on processes, not people. Here are 4 factors that set this error in motion and allowed it to nearly reach me.

1. My physician wrote an ambiguous order. The daily dose of warfarin 10 mg I had been receiving was not discontinued when the prescriber wrote the 7.5 mg dose on Thursday morning. Clear communication of dose, especially when titrating doses of high alert medications like warfarin, is essential. A process for doing this should be meticulously defined and used.


2. My current INR was not available to the pharmacist. Warfarin is titrated based on a patient's therapeutic response (genetic differences influence the way the drug performs and a multitude of other variables make its therapeutic window maddeningly tight). Absent current INRs, pharmacists cannot perform meaningful dose-checking, a vital part of pharmacy practice.


3. A "high dose" alert in the pharmacy computer system was absent or over-ridden. While 17.5 mg of warfarin is a conceivable dose, it's not a typical dose, especially for a new warfarin user who had shown a predictable response to therapy during the initial days of therapy. Alerts in commercial software programs call attention to orders with unusual doses, enabling the pharmacist to review, and when necessary, intervene before a wrong-dose error reaches the patient.


4. My nurse lacked knowledge of the drug dose & how INR values informed the dose. Warfarin is a high alert drug. On a busy medical-surgical unit, validation of knowledge for high alert drugs should be part of initial competency validation. Additionally, readily available drug resources should be available to front line nurses.

Here are 2 factors that saved me from the overdose:

1. Something didn't make sense to me, so I questioned the plan of care. My clinical condition was such that I could self-advocate, and I did.

2. My nurse did not see herself or the system as infallible. When faced with the possibility that something could be amiss, she double-checked. It's important to realize that I likely would have backed down if the nurse had not been so willingly to call the doctor and double check the order.
A shorter version of the story looks like this:





As I've told this story over the years, most people identify the nurse's knowledge deficit as the primary cause of the near-miss. Her knowledge deficit is a disturbing risk point, but, in my mind, no more so than the events that allowed the erroneous dose to be ordered, entered on the MAR, and brought to my bedside. Should the doctor have been able to communicate an unambiguous dose? Yes. Should the pharmacist have recognized an atypical dose and intervened before dispensing it? Yes. Should the nurse have had better knowledge about warfarin dosing? Yes.

Blaming any one person for the hole in their slice of the cheese is futile. System solutions, like "warfarin order strategies that prevent ambiguous doses from reaching an electronic MAR" and "validating nursing knowledge of high alert drugs during initial competency validation," make each hole smaller. Closing any hole works. Closing them upstream works best.

The last thing I'd encourage you to see is that while I may have saved myself, but I couldn't have done it without my nurse! Thanks to all of you, and happy Nurses Week!

Can you hear me? Can you hear me now?

Welcome to the ongoing celebration of Nurses Week 2009, honoring nurses and nursing sensibilities. Today, it's all about hearing, and the good things that hearing makes easier, like listening and communicating.

Talking "patient safety" with nurses is like preaching to the choir, with the choir finally getting access to sheet music.

A few words about the valuable roles nurses play in making patients safe:




Finally, a look at standards and emerging best practices:

And a small musical tribute that says just a little bit about the important work you do:

Feel free to use the comments section to add suggestions to round out the playlist of songs celebrating nurses. Flo & Bo struck out in several genres, notably country and hip-hop. But hey, it's your party, you can cry if you want to.

Flo & Bo say "Hello"!

Happy Nurses' Week! Each day this week, Florence dot com, a real-time patient safety primer, is going to celebrate nursing sensibilities, recognizing the key role you play in making patients safe.

This patient safety blog is named for Florence Nightingale because I wanted it to reflect the kind of advocacy Nightingale did, advancing health and healthcare with a keen eye on the realities front line clinicians face. I hope you'll enjoy this week-long tribute to how you, the descendants of Florence, continue to make patients safe.

Florence Nightingale is often associated with the post-World War II "nurse-as-doctor's-helper" figure that populated novels, TV shows, and ads as baby boomers and Gen-Xers grew up. But this image was more about how women in that era were seen than about nursing, Nightingale-style.

I often use this picture when I speak, noting that nurses used to kneel down, pledging our intention to do good, right, and just things in our professional capacity. Most people laugh, readily identifying the most obvious things that have changed: that apron, that cap; that position, that hairstyle, and the fact that they're both women.

But while a deeply felt desire to "do right" by patients remains a stronghold of nursing, it's worth noting that pledges are now supported by emerging practices and norms, offering increasingly reliable ways for caring people to turn good intentions into desired outcomes.

I hope you'll visit every day in the coming week, find the tributes and take-aways helpful, then subscribe to Florence dot com. To appeal to your senses, here's what Flo & Bo have in store:

Thursday, 5/7: Can you hear me? Can you hear me now?
Friday, 5/8: Do you see what I see?
Saturday, 5/9: Something smells good
Sunday, 5/10: A touching tribute
Monday, 5/11: While it's sometimes tempting to eat the young, here's a better recipe
Tuesday, 5/12: Happy Birthday, Miss Nightingale!

Feel free to use the comment section. It's your party!

Nuts!

Peter Pronovost may think we're nuts. Actually, he said doctors and nurses work in a system that's nuts. But, I'll toss off the virtual nurse's cap this morning, and offer the same advice I'd give to my kids: Nutty is as nutty does.

Pronovost, a well-respected patient safety advocate and practicing clinician, appeared in a Wall Street Journal blog post a few weeks ago, sharing his views about safety gains that could arise from hospital-industry-regulatory collaboration modeled on aviation partnerships. Advocating for measures that transcend what professionals closest to the secretions can pull out of their, well, shall we say, personal supply cabinets, Pronovost pointed out that clinicians who work in hospitals need better and more effective tools to prevent mishaps.

If an infusion meant to be delivered to the epidural space can kill a person if it's inadvertently infused intravenously (as has tragically occurred many times in the past), safest practice would be to make epidural tubing incompatible with the cousin ports populating the patient's nearby IV tubing. An engineered device constraint is far more likely to prevent patient harm than reminding clinicians who manipulate the lines to "be more careful" and placing labels on tubes and lines. Especially when the therapeutic care environment looks like this:

photo used with permission

Personal diligence and adjuvant labeling shouldn't be abandoned, but a constraint like incompatible tubing is a far more effective way to derail a significant error that has been set in motion.

If you've been following Flo's posts for the real-time patient safety lessons she offers, it's worth reviewing the medication use process, recalling that the likelihood of catching (and correcting) an error increases the further upstream the error originates. This makes sense since an error in the prescriber's order has the potential to be picked up by the person who dispenses the drug, the person who administers the drug, or the patient.

Slide based on modeling described by James Reason

Tubing misconnections are errors that originate downstream, in the administration node, meaning there are limited opportunities to uncover them and prevent harm before they reach a patient. Engineered incompatibilities between epidural and intravenous line ports and connectors are powerful constraints, one of the few reliable ways to catch wrong-route errors arising from a clinician's slip, trip, or lapse at the point of medication administration.

When cross-functional stakeholders join forces in healthcare, as they have in aviation, your patients may be as safe while giving birth in the U.S. as they are while flying commercial.

This is not what I envisioned when I became an intrapartum nurse some years ago, but apparently what I should have been saying all along is, "I'm the SafetyNurse, fly me!" (My husband says I've been cleared for take-off, but he may be saying something unrelated to this topic. In any event, I hope you'll travel safely!)