Change of Shift is changing the world

Change of Shift is up at Emergiblog. Take a look to find out what nurses are talking about.

I included a post I wrote last Sunday about how social media (SM) may be the equivalent of the "big reveal" on a reality TV show, only what we're revealing on blogs and Twitter is the culture of healthcare. Making healthcare more transparent by sharing not what should be done, ought to be done, or even what we wish we could have done. SM seems to be a vehicle in full-throttle that captures what's actually done.

That said, I'm wondering how professionals who blog and tweet feel about their stories being picked up and used to illustrate how well the systems frontline clinicians rely on work (or, in many cases, don't work.) The knowledge, attitudes, values, and beliefs of individuals are reflected in the accounts we share. This information is often very personal, and it may reflect organizations individuals chose to identify. There's a lot of "hot talk" about respecting the privacy rights of patients in social media, but what about others?

My work focuses on how people perform within a system. The goal is to improve outcomes by improving the fitness of the system, being mindful of the strengths and limitations that humans bring to high-stakes endeavors. But this is not a universal approach, and "blame, shame, and re-train" approaches to performance improvement remain operational (even if they are not tacitly endorsed). For this reason, I chose not to "hot link" the stories I shared lest it draw unwelcome attention to individuals who simply shared a "day in the life of" account.

I'd love to have some feedback. Am I being overly cautious? Is posting and tweeting a "let the buyer beware" endeavor?

Trolling for patient safety in social media

People are asking lots of questions about social media (SM). More specifically, I think, we're wondering whether Facebook, Twitter, and blogs have meaning beyond what I've recently counseled my 21 year old daughter to beware of: trolling for amusement.

SM can knock on the door of its evil cousin, "addiction." It has, on occasion, claimed rather large chunks of my life in a way I failed to notice or care about while engaged. So am I a Twaddict? A Blogopath? Am I locked in to Linked-in?

Life is meant to be lived. Not mindlessly thumbing through electronic messages in hopes of finding something more interesting than what's happening where you are. So I've been reflecting about whether time spent at social networking sites can be counted as really living?

I don't know for certain that social media is "life," but I think it reflects life. More specifically, it's a barometer of culture. As a person who follows how culture in healthcare organizations impacts safety very closely, I find that SM opens a window into experiences and settings that are otherwise closed. Since you can only learn--individually and collectively--from mistakes and near-misses that you know about, I think greater transparency is among the greatest gifts SM offers the discipline of patient safety.

Here are just a few examples that captured my attention in the past few months. Since this is not a forum to fully deconstruct each event, I'm titling each to show the behavior or belief that undermines safest practice:

• It's okay to carry things that will be injected into patients' veins in the same manner as a Bic pen: A promising young nurse shares stories about her entry into the nursing profession. One day, she photographs what she carries in her pocket. Scissors, tape, "flushes," and pens are among the things she finds helpful to store there.


• We all have nights from hell: A seasoned intrapartum nurse describes a busy shift where she cares for multiple high-risk patients, all of whom are receiving high alert medications (those highly likely to cause harm if used in error). Staffing inadequacies and a pervasive "get 'r done" culture prevent post-procedure medication and patient monitoring. Everything turns out okay in the end.


• Smart people don't make stupid mistakes: A resident caring for a patient receiving intraoperative dialysis takes a picture of the machine used to perform dialysis. She questions whether it's necessary to have adjunct labeling ("Dialysis Only. Do Not Drink") affixed to the front. And she asks this in a way that suggests this photo may wind up in an upcoming collection of "Darwin Awards."

People share their stories and experiences in SM venues in ways that often remove standard filters, many of which we rely on to be successful (or at least functional) in "real life." Bloggers and tweeps are not in "inspection mode," and they're not usually engaged in defensive posturing. Most accounts come from regular people, telling stories about how they take on the business of providing care. Details about obstacles faced, choices made, and opinions expressed reflect the culture of healthcare.

I saw this from Dr. Val, tweeting from a live speech by Francis Collins last week:

Collins: If you want to find a cure for cancer, you don't need to just research cancer. The answers may come from somewhere else. #RSOS.

So, too, with curing what ails healthcare.

Tuesday Afternoon

I've been "chasing the clouds away" here in stormy Atlanta. But there are interesting things to report from other venues, too.

First, Grand Rounds, the weekly blogging carnival is celebrating its 6th anniversary at Residency Notes. Colin Son, a first year surgical resident, is surely one of the busiest people on earth. But he's making time to continue blogging and lending support to Grand Rounds. (Maybe this is a positive outcome of taming residents' work hours?) In any event, Colin featured the list of 25 Patient Safety Tweeps today, a nice indication that "patient safety" is hitting the radar screens of young professionals.

Residencies and patient safety were in evidence in other ways this week. I picked this up in Twitter feed:

@alinahsu: U of IL: residents must report 5 unsafe conds or near misses per year in order to move on. #ahrq09

(If you're learning how to "read" tweets, this message means that someone named @alinahsu believes that at the University of Illinois, residents must report unsafe conditions and near misses as a condition of satisfactory performance and to advance during their residency years.)

I wouldn't take the contents of any one tweet to the bank, but this one is a nice indicator of positive change in healthcare's reporting culture, coming from a field reporter. Social media (things like blogs, Twitter, and Facebook) are emerging as barometers of safety culture: Busy clinicians won't write a paper about things that please or annoy them, but they will drop a line or two. Here's an on-the-fly assessment about a usability issue, this one running at the top of a blog:

"Whatever the VA paid for these tablet computers that we use to consent patients, well it was too much. These things suck." — txmed

I spent a few hours this morning at Mercer University's School of Pharmacy, talking to 2nd and 3rd year students about culture and communication and how these things affect medication safety. And I'll take the online "thank you" from a pharmacy student with a newly minted Twitter account (@preventionjunky) as another positive sign that young professionals in the pipeline are going to be the tipping point in patient safety.

Finally, I had fun hosting "Bob the Nurse," the nurse action figure with too much time on his hands. Click on over to one of Keith Carlson's blogs to see how Bob Improves Drug Safety. I'm still laughing about his Zilactin walking stick.

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.