This is a great explanation of how the overload that occurs in a nurse’s job can result in distraction and medical errors.

As of 2006, nearly 40% of American hospitals employed hospitalists. These individuals are physicians who are employees of the hospital. They do not have a private practice and instead, manage the hospital care for patients admitted from physicians in the community.

There is a wide range of pressures on hospitalists. They are constantly having to prove their worth. The Society for Hospital Medicine Career Satisfaction Task Force divided these pressures into the nature of the work, the nature of the work environment, career and organizational issues, personal issues, and external influences. Look at just one aspect of the role, the nature of the work:

• High acuity/complexity of illness/lack of predictability
• Life and death implications of clinical decisions
• Provider interdependency and communication
• Limited patient information
• Administrative and documentation requirements
• Medical legal risk
• Potential hostility from patient’s family

Teaming a hospitalist and a nurse practitioner is one way to address a wide range of concerns, such as safety, quality, cost reductions, education, throughput, around-the-clock coverage, and medical staff leadership. (1)

Some of the ways that hospitalists and nurse practitioners can work together include:

• Divide up responsibilities for hospital admissions
• Provide coverage for the entire hospital patient population – issue orders, assess patients with changes in status
• Supervise residents
• Respond to rapid response requests
• Perform procedures
• Respond to cardiac arrests/codes (2)

It is clear that hospitals that perfect team work, that reduce barriers between professionals, will survive. They will have fewer bad outcomes, and more satisfied patients.

(1)SHM Career Satisfaction Task Force
(2) Johnston, J. Jones, L. McNulty, R and Andrews, C. The NP/Physician Hospitalist Team Connection, AMSN Newsletter September/October 2011, page 1

Obtain more information about the role of nurse practitioners by reading Patricia Goode RN, ANP/FNP’s chapter, “Nurse Practitioner Liability Issues”, in the fourth edition of Nursing Malpractice, edited by Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell and published this year in 2011.

Pat Iyer is president of Med League Support Services, Inc.

Hospitals try to eliminate back injuries by teaching classes in body mechanics, providing back belts for patients, train in safe lifting techniques, and do manual lifting. There is strong evidence that each of these techniques is nto effective in reducing caregiver injuries.
Both patients and nurses can be injured by the activities associated with care. Nurses are aging, as a population, and are at higher risk for microtears in their back muscles caused by lifting. The activities associated with nursing involve strain on the back. The physical care associated with washing patients, getting them out of bed, or lifting them up in bed is physically demanding, unpredictable, and done in difficult conditions. Patients are at risk for falls, fear of falling, and loss of dignity.

I have pulled more patients up in bed than I can ever calculate. I have leaned over beds to put on clothing or support stockings, move people off or on stretchers, on and off toilets, change sheets, or apply equipment. My back bears the reminders of these years of strain.

How do you reduce injuries to nurses and patients? These are some strategies that work:
• Use patient handling equipment or devices.
• Have no lift policies.
• Use patient lift teams.
• Use patient assessment protocols.
Patricia Iyer MSN RN LNCC is president of Med League Support Services, Inc.

I recall when my father was in ICU nearly 33 years ago, he thought the alarms represented fire trucks, and could not understand why there were so many fires in the blocks around the hospital.

Alarm fatigue can be deadly

But technology relies on humans to hear, interpret, and respond to alarms. Sometimes alarms are false alarms and do not signify anything. Sometimes alarms are annoying; the nurses turn them off. Sometimes the alarm is turned off because the patient is being taken off the equipment temporarily and the nurse forgets to turn it back on. Sometimes the nurse mis-programs a complicated piece of medical equipment. And sometimes the volume is turned down, or the nurse is at a point on the nursing unit where she cannot hear the alarm.

The Boston Globe provided a special report on this subject. It offers the perspectives of the healthcare providers and the manufacturers. When an investigation of a patient death associated with an alarm failure occurs, it is often not the equipment at fault, but the staff who did not respond to the alarm. Healthcare professionals and manufacturers are trying to create safety solutions, for example, by creating more technology, like signs in the hallways to warn staff of an alarm. For more information, read the report and watch the video.

Investigating a claim
1. The biomedical department is typically asked to look at a piece of equipment associated with an untoward outcome. The hospital may generate a report that details their findings. This may or may not be discoverable.
2. The manufacturer may be asked to examine the equipment, and they also generate a report.
3. The hospital will have discoverable policies on setting and checking alarms.
4. The medical record may incorporate flow sheets with boxes to check off that alarms were set.
5. Cardiac monitors that detect arrhythmias may spit out paper that is time stamped. These times should be compared with the medical record.
6. Nurse defendants and fact witnesses should be asked about the healthcare environment, the frequency of alarms, the responses, and the nursing practices associated with alarms.

Deaths from medical errors are compared to plane crashes

Did you know those numbers are FALSE? Those numbers are way too low! First, the numbers came from the Harvard Practice Study, which looked at 30,000 New York State hospital records. The study did not include deaths caused by care in nursing homes, doctor’s offices, outpatient surgery centers, and other non-hospital sites.

The study also did not include errors that were not documented in the medical record. Even the physician who led the study said “that if we watched people delivering medical care, we’d see up to 17% of care involved errors”. That same Harvard Practice Group study was done using 1980’s medical records but wasn’t published until 1991. So that report, which is still being cited by the medical profession and media sources, only reported partial information “at best” and is now well over 20 years old. Any information contained in it is severely outdated! Health care is even more complex today which means it provides many more opportunities for medical mistakes and errors.

The original studies are found at the link below: Incidence of Adverse Events and Negligence in Hospitalized Patients — Results of the Harvard Medical Practice Study I
Troyen A. Brennan, M.P.H., M.D., J.D., Lucian L. Leape, M.D., Nan M. Laird, Ph.D., et al, New England Journal of Medicine 1991; 324:370-376
The Nature of Adverse Events in Hospitalized Patients – Results of the Harvard Medical Practice Study I, Lucian Leape MD and others

See the full text articles at February 7, 1991

A new study released in November 2010 by the Office of Inspector General confirmed that about 180,000 Medicare beneficiaries die each year from an adverse event in a hospital. Physician reviewers concluded that 44% of the adverse events were likely or clearly preventable. One in seven medicare patients were harmed by medical errors in hospitals. See the report at www.oig.hhs.gov.

A delay in diagnosis of a fracture can result in significant pain and suffering.

The sound of a body hitting the floor can bring healthcare providers running. When the sound occurs when a nurse or aide drops a patient during transfer, the next sound may be, “Oh no.” This type of fall may occur if the staff do not use proper body mechanics, the patient is uncooperative, or the transfer requires more people that were actually used for the procedures. Taking shortcuts, cutting corners, and being rushed can spell disaster. The result may be a fracture, a head injury, paralysis and death. The situation is worsened when the staff member involved does not report what happened.

What drives the urge to cover up? Fear, guilt, and desperation may push the facts underground. In one case, two aides dropped a patient while transferring her into a Hoyer (hydraulic) lift. The patient suffered two fractured hips. The aides did not tell anyone for fear they’d lose their jobs. In another case, an aide tried to transfer a patient from a bed to a wheelchair, and the patient fell, fracturing her leg. The aide did not tell anyone what happened. Subsequent nursing staff observed the patient crying in pain, and the truth came out. In a third case, the fact that a woman’s leg was fractured became evident when her broken bone eroded through her skin.

In the absence of any documentation to explain how the fracture occurred, the defense may assert the fracture was a spontaneous one. This theory is based on the concept that bones may become brittle and fracture on their own. This is certainly true of patients who have cancer, hypoparathyroidism, Paget’s disease, and severe osteoporosis. However, spontaneous fractures of the hips are rare, and should stimulate a suspicion of trauma. The facility administrators need to perform an investigation to talk to the nursing staff involved in caring for the patient before the symptoms of the fracture were detected. An orthopedic surgeon and radiologist should review the x-rays to look for evidence of bone disease. The healthcare facilities need always be concerned that staff have adequate equipment and help to safely move patients.

In most cases, insurance companies will get out their checkbooks. These cases are usually indefensible.

Learn more about falls by checking out this value pack.

Pat Iyer is president of Med League and reviewed many cases involving falls during her career as an expert witness.

Suicide is the #2 most common sentinel event

Suicide in hospitals is more common than you think. The Joint Commission reports it is the second most commonly reported sentinel event with 816 events reported as of June 30, 2010. Most of these suicides occur in psychiatric hospitals, followed by general hospitals. Most people commit suicide by hanging. I recall hearing of a man who committed suicide on a medical surgical unit of the hospital where I worked. He hung himself from the pole in the closet. Other people commit suicide though a fatal fall. We have worked on several cases involving people who have jumped off the roof of the hospital. Other fatal falls involve falling down a staircase, balcony, laundry chute, or upper story window.

Healthcare providers are expected to be attuned to recognize the symptoms of suicidal intent. These include changes in eating or sleeping patterns, withdrawal, feelings of guilt or worthlessness, fatigue, feeling helpless and hopeless. Some individuals identify a plan to kill themselves. And some are at high risk for suicide: the unemployed, unmarried, substance abuser, the person with a history of previous suicide attempt, and having a mood disorder.

The liability issues center around whether the suicide was foreseeable and preventable. Here are some factors that influence that determination:

1. Was the environment safe? Did the facility use non-breakaway bars, rods or safety rails? We know of cases of patients who have committed suicide by putting plastic bags over their heads, hanging themselves from light fixtures, or opening windows to climb out.
2. Did the staff observe the patient to identify the risk of suicide, reassess the risk, and look for contraband if warranted? In one case, a man became very confused after surgery, kept climbing out of bed and pulling out his intravenous lines, and yet the nursing staff did not intensify monitoring. He threw himself through a glass window and died. The jury found the nursing staff negligent.
3. Did the staff make the required observations once the patient was recognized as being suicidal? We know of a case that involved falsified medical records: the checks of the patient were recorded as being made, but were not actually carried out. The case settled.
4. Were the staff adequately trained to recognize suicidal behavior and thoughts?
5. Was there adequate staffing to provide the needed care? In the case of the falsified records, the staff responsible for making suicide checks were pulled away to perform admission assessments.
6. Did staff communicate with each other about the risks of suicide?
7. Was the patient placed in a location where he could be observed? In another case, a man waiting to be admitted to a psychiatric hospital was sent to the x-ray department by himself, and climbed a staircase to the roof of the hospital, where he jumped to his death. The defense won this case.

Healthcare providers have the duty to protect the vulnerable. The suicidal patient fits squarely within that definition. In most cases, insurance companies will get their checkbooks. These cases are hard to defend.

For more information, see our teleseminar, Death in Seclusion or Restraints, read More than the Blues and Risk of Stroke Increases in Hopelessness.

Pat Iyer is president of Med League. She has testified in cases involving suicide.

Wrong site wrong patient surgery-inexcusable medical error

“Everyone was under the assumption that when the so-called universal protocol was implemented in 2004, it would lead to a decrease in these ‘never events,’ ” said study lead author Philip F. Stahel, MD, PhD, director of the Dept. of Orthopedic Surgery at the Denver Health Medical Center. “Not only did they not decrease, they increased. In the first few years, the universal protocol did not prevent these never events from happening.” Read more

Who are the surgeons at biggest risk for performing wrong patient or wrong site surgery? Orthopedic/pediatric, general surgery and neurosurgeons. Not surprisingly, they are a bit defensive about the results of this study.

How do you prevent wrong patient and wrong site surgery? Simple: follow the protocol step by step.

How does this happen, you ask? The Joint Commission looked at the risk factors in its Sentinel Event Alert in August 1998. One factor is production pressure. Move the patient in, operate, move her out, clean the room, move in the next patient. Emergency surgeries are high risk, as well patients with unusual physical characteristic, including morbid obesity or physical deformity. Staff working with unusual equipment or patients having multiple surgeons and procedures are at increased risk.

What can operating room staff do to stop this inexcusable medical error?
1. Correctly identify the patient. One of Med League’s operating room nursing experts worked on a case of a childless woman who got someone else’s tubal ligation. It is notoriously difficult to reverse a tubal ligation. No one identified her before starting surgery.
2. Ask an awake and alert patient to identify the surgical site. My mother carried a sign into the operating room before her right lung wedge resection. Her sign said, “It is my right lung.” One of the OR nurses told her she was cute. She retorted, “No, cautious.” A teenager who needed a left knee surgery wrote on her right knee, “Doctor, if you are looking at this knee, don’t.”
3. Create and use a verification checklist that includes the operative consent and any imaging studies.
4. Obtain oral verification of the patient, surgical site, and procedure in the operating room. Involve everyone, including the surgeon, in the verification. One of Med League’s operating room nursing experts worked on a case which involved a failure to correct identify the site. The patient came into the operating room at change of shift. The incoming staff assumed the outgoing staff had performed the verification process. She received surgery on her right knee instead of her left.
5. Expect to not get paid for surgery performed on the wrong patient or site. CMS and private payors will no longer pay for these errors.
6. Administrators, do not tolerate surgeons who want to rush people through the last and most important safety check in the OR. Leadership is top down. There can be no tolerance for shortcuts.
7. Get out your checkbook. These cases are inexcusable and will not happen if people follow the protocols designed to protect the patient.
Read more about why healthcare providers do not follow the rules part one and part two.
This is an overview of a recent article in New England Journal of Medicine about the factors that led a hand surgeon to operate on the wrong site.
Pat Iyer is president of Med League.

Nursing shortage will worsen

The United States is in the midst of a nursing shortage that is expected to intensify as baby boomers age and the need for health care grows. In 2010, the average age of the RN is be 45.4. The employment of RNs older than age fifty is growing faster than among any other age group. With the average nurse in her or his forties, and a fairly substantial number of nurses in their fifties and sixties, a large segment of the current workforce will be retiring in the upcoming years. These individuals cannot be replaced, either in experience or in sheer numbers. Nurses will start to retire at the time baby boomers begin turning 65 years of age and start using more care. Forecasts for a registered nurse shortage in 2020 range from 400,000 to more than 1 million.

In addition to the number of RNs who leave nursing, there are almost one-half million licensed nurses who are not employed in nursing. About 69 percent of the 490,000 RNs not employed in nursing in 2000 were fifty years or older. [42] The problem is compounded by the fact that nursing colleges and universities are struggling to expand enrollment levels to meet the rising demand for nursing care. More than one million new and replacement nurses will be needed by 2012. There are nearly 100,000 vacant nursing positions in long-term care facilities on any given day, and the nurse turnover rate exceeds 50 percent. The shortage is costing long-term care facilities an estimated $4 billion a year in recruitment and training expenses. This turnover statistic is in comparison to a survey that found that the average registered nurse turnover rate was 13.9 percent, the vacancy rate was 16.1 percent, and the average RN cost-per-hire was $2,821.

This all adds up to lots of need for nurses and not enough supply. From a patient safety standpoint, it is not encouraging. For an interesting infographic on the nursing shortage, see this link.

Sources:

http://stats.bls.gov/oco/ocos083.htm#outlook

Buerhaus, P., D. Staiger, and D. Auerbach, “New signs of a strengthening US nurse labor market?” Health Affairs (November 2004): 17.
What Works: Healing the Healthcare Staffing Shortage, http://www.pwc.com/us/en/healthcare/publications/what-works-healing-the-healthcare-staffing-shortage.jhtml
www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm, last accessed July 18, 2005.

The nurse is a patient advocate

A New Jersey plaintiff attorney lost a $19 million verdict when a state appeals court found multiple trial errors. Med League supplied one of the expert witnesses for this case. The case involved an alleged delay in ordering a cesarean section, which caused cerebral palsy in the child. In Kowalski v. Palav, A-5348-07, the nurse on duty when Bonnie Kowalski went through labor, testified she repeatedly told Dr. Aravid Palav, the obstetrician, that she was concerned about the dropping fetal heart rate. She believed the patient needed a cesarean section without delay. But the physician believed the patient was likely suffering from appendicitis as the cause of severe stomach pain, and the fetus was not in jeopardy.

Nurse Zeh testified about her concerns about the condition of the fetus. She said it was often unclear whether she was reading the baby’s heart rate or that of the mother, who was writhing in pain. When the physician objected that the potential prejudicial effect of that evidence outweighed its probative value, the judge determined the nurse’s testimony was relevant only the nurse’s decision to go up the chain of command to press for immediate delivery, not to the physician’s alleged deviations from the standard of care. The jury found the physician deviated from the proper standard of care, caused harm to the child, and awarded $18.9 million.

The Appellate Division judges held that the nurse’s testimony should have been excluded because it suggested that Palav deviated from the standard of care because he failed to perform a cesarean section in the face of her insistence that the baby’s condition was deteriorating. The judges held the nurse was not qualified to present testimony that could be inferred as an expert opinion.

Read more at www.njlj.com, August 30, 2010.

This case illustrates the fine line nurses walk when they advocate for their patients. The nurse is held to a professional standard of performance. Nurses are expected to recognize when a physician’s behavior is jeopardizing a patient. Nurses are obligated to question the physician, and if not satisfied with the response, to go up the chain of command to obtain resolution of the concerns. Had Nurse Zeh not gone up the chain of command, she could have been criticized as being negligent for failing to protect her patient.

The irony in this case is that Nurse Zeh’s explanation of her decision to speak to her charge nurse and nursing supervisor about Dr. Zeh showed she carried out her obligation to use the chain of command, but also implied a criticism of Dr. Palav’s decisions. This is exactly the hot spot that places nurses in the uneasy role of tackling the decision making of physicians. They must take on even the most intimidating of physicians, even at the risk of becoming objects of the physician’s anger. See “How Harshness Harms Patients”. But if they testify, as did Nurse Zeh did, about their interventions, they can be seen as offering an expert opinion on the standard of care for an obstetrician. What a fine line!