Please mess with Texas

When I was a Labor & Delivery nurse, and long before I had a better conceptual framework for understanding quality in healthcare, I learned two words that summed up what families valued during their childbirth experiences: "safe" and "satisfying." While these weren't all-inclusive quality markers, they're foundational elements that signaled quality. They still do.

"Satisfying" is a concept that belongs to individuals. The way pain is relieved, how much restoration of function is enough, what a good birth, or a peaceful death look like are outcomes subject to interpretation, outcomes rightly defined by individuals. So long as they're competent to make decisions and their choices don't interfere with others, consumers should own "satisfying."

On the other hand, "safe" can't venture far in territory that's defined by the perception of individuals. Here's one reason why: Each of us is a statistical sample of one. A good outcome may arise because the people and processes effecting the experience are fit, robust, and reliable. In a word, safe. It's also plausible that one good outcome represents a lucky spin of a very damaged wheel. When comparative processes are absent, one outcome tells little about safety. This is why licensing, professional standards, regulatory oversight, benchmarking, quality metrics, error analysis, and peer-review processes are deeply rooted in industries that post excellent safety records. Measures like these unearth information from a variety of sources, revealing data not readily apparent to individual consumers.

Quality assurance processes are far less perfect in healthcare than they are in other high-stakes, high-consequence industries. In the US, over 100,000 people die each year as a result of medical error and healthcare acquired infections, adverse events that cost billions and rob citizens of peace when they are most vulnerable. In healthcare, we're struggling to align individual competency, personal accountability, and good design in a way that's more reliable, better able to deliver the predicted outcome, and, well, safer than it currently is.

Which is why a case in Texas, in which two registered nurses face felony charges for good-faith actions aimed at protecting patients, should concern you. The nurses, both employed at a county hospital, reported concerns about a physician's practice to the Texas Medical Board. Their report included numbers (but not names of patients) that medical board officials would need to identify medical records for review. As a result, both nurses:

• were charged with "misusing official information" (criminal charges arising from the act of disclosing medical record numbers to the Texas Medical Board)
• were fired from their jobs
• face $10,000 fines and up to ten years imprisonment, if convicted

Let me be clear here: A nurse's report of concern about a physician's practice does not constitute a professional sanction. Reports of concern are pieces of data, not judgments. In a healthy system, reports of concern about licensed professionals result in peer-review. In a sick system, reports of concern result in acts that punish those who raise them (and intimidate those who might consider raising similar concerns in the future).

One of the biggest challenges to healthcare safety and quality is under-appreciation and under-reporting of things that have the potential to cause harm. Healthcare is a "no harm, no foul" game, and playing by these rules means we often miss the chance to fix a known problem before actual harm occurs.

In a culture where safety is valued, people who report things that are outside of perceived norms are highly valuable players. But in Winkler County, Texas, they could be criminals.

You can read more about this case, the charges, and contribute to the nurses' legal defense fund, set up by the Texas Nurses' Association, by clicking here.

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!)

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!