!Patient safety
---
agk's diary
11 April 2022 @ 15:33
---
written on Pinebook Pro at kitchen table
as excited roommate talks about negotiating a
better contract with the hospital that's hiring her
---
I wrote a discussion board post for school about
medical errors. I swear the purpose of the class is
to build a list of radicals to send to union-
busting firms. I'm half-serious!
We watched a video by the US Agency for Health-
care Research and Quality. A woman's family was
victimized by medical errors; it's her account of
what happened. Our prompt: "Briefly discuss what
happened to Sue's family. Discuss your thoughts
and feelings."
Sue's son sustained a preventable lifelong serious
brain injury. Her husband died of treatable spinal
cancer. Both tragedies were cascading system and
practice failures, entirely preventable. Clinical
observations weren't investigated with lab tests
on multiple occasions. Sue's concerns were ignor-
ed. She wasn't told information she needed to
make decisions. Results weren't acknowledged or
acted on by the attending physician. A test was
interpreted wrong. Bad interpretations were un-
challenged.
Sue's clearly felt lots of anger. She holds it to-
gether and channels anger into advocacy. Her story
humanizes facts: medical error's a leading cause
of death in the US and Canada. Probably a major
cause of disability, too.
My experience of nonfatal errors involves systems
problems: understaffing, bad nurse-patient ratios,
not enough resources at point of care, poor nurse
morale related to the above and increasing nurse
health insurance premiums, high student debt, cut
COVID/FMLA sick-leave compelling nurses to work
sick/exhausted.
There's high turnover, increasing proportions of
short-term H1B visa nurses and "traveler" agency
nurses, providers outsourced to agencies, hospital
chains consolidated by private equity firms (with
policy changes, cost-cutting measures, record
profits and executive compensation packages), etc.
Shortages chosen by administrators produce short-
term profit. Nurses and care techs ration care and
attention at the bedside.
At the point of care and management close to it,
these issues are "bad weather" we work through.
"Bad weather" boils down to money-making being
institutionally and legislatively valued over human
life and dignity.
Good nurses develop safety cultures as "umbrellas,"
"shelter," "heat" for patients and floor staff to
have the best outcomes and labor conditions possi-
ble in routinely "inclement conditions," with "poor
visibility" of patients' holistic circumstances,
when what's in the moment and has to be charted
takes priority.
A few more issues I think make preventing medical
errors in the US hard:
RaDonda Vaught's prosecution with internal incid-
ent report data reflects the problem of institut-
ions displacing blame for failures onto scapegoats,
substituting cheap interpersonal communication
strategies and individual wellness/selfcare (on
your own time/dime) for system change. RaDonda's
scapegoating damages trust health workers place
in incident reporting. Incident reports are neces-
sary for performance improvement/risk management
to build "shelter" for the safest care possible
given "inclement weather."
Like teacher unions, nursing unions advocate for
patients in contract negotiations---especially safer
nurse-patient ratios. Company negotiators threaten
nurses' health insurance to force unions to drop
safety demands. Who'd trade their child's insulin
or husband's chemo for patient wellbeing? How bad
does it feel to be put in this position?
State and national nursing associations advocate
legislative remedies. Our lobbying and campaign
contribution budgets don't compare to the lobby
for industries that employ us. The Kentucky Nurse
Association bill to address the nursing shortage
with scholarships was ignored in the state legisl-
ature. Instead an industry bill to lower educat-
ional standards and import more disposable H1B
visa nurses was fast-tracked. KNA doesn't even try
to fight for safe ratios or COVID sick-leave.
Staff nurses complain about assertive patient fam-
ily members---often current or past nurses or care
techs. Patients with strong bedside advocates are
often resented by nursing staff, maybe because
(I'm using language I've heard from floor nurses)
they "suck up too much of our time" or "pester
us," disrupting the delicate balance of nurse time
management. If visiting a room with an advocate
takes twice as long, nurses put off going on the
principle of justice (all patients should get
nurse time rationed fairly).
How do we, nurses with time limited by ratios
and the task burden we're assigned, work with
advocates instead of against them, not skimp on
care of patients who don't have advocates and
don't advocate for themselves, and avoid errors?
When labs weren't ordered on an obviously, persi-
stently jaundiced baby with increasing impair-
ment, despite mom's expressed concern, if Sue's
son was my patient, I hope I'd crossmonitor other
health workers and SBAR the provider to request
labs. If the provider tried to blow me off, no
labs on that baby ain't concerning or uncomfort-
able, but a safety risk! I'd name the risk twice
to stop the line. If the provider wouldn't order
labs, I'd ask my supervisor how to proceed.
Maybe I could've saved Sue's starfish, but the
beach is crowded with so many. My country's
medical industry needs radical change.
