Sunday, May 01, 2011

I wish we were less patient

The sad case of Kimberly Hiatt, a Seattle nurse who committed suicide months after being disciplined for administering a fatal dose to an infant, is starting to make the rounds. Josephine Ensign, for example, concludes her blog post on this by saying:

I am left with many questions. Why was the nurse treated so differently from the dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes . . . what do I teach my students to do?

We can never know, of course, whether the suicide was related to the incident itself, the disciplinary action, or indeed, some other aspect of Hiatt's life. But the sequence of events will cause many to draw the connection between the way Hiatt was treated after the accident and her death. In any event, though, the ambiguity as to whether or not it was connected does not take away from the kinds of questions raised by Ensign.

Captain Sullenberger raised this issue during his talk at MIT this past week. Citing this particular disciplinary case, he noted that the kind of approach taken was "not particularly helpful" in creating an environment in which crew resource management would be effectively implemented.

My regular readers know that my former hospital faced a similar issue following a wrong-side surgery. Would we punish the surgeon and others involved in the case? We decided not to, not because they had suffered enough themselves from the error, but because we felt that a "just culture" approach to the issue would suggest that further punishment would not be helpful to our overall goal of encouraging reports of errors and near misses. The head of our faculty practice put it well:

If our goal is to reduce the likelihood of this kind of error in the future, the probability of doing that is much greater if these staff members are not punished than if they are.

Punishment of those involved in this case also would have diverted attention from the failures of senior management in doing its job. As Tom Botts from Royal Dutch Shell commented about deaths on one of his company's oil rigs:

It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organisation to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.

It also would have diminished the likelihood of widespread interdisciplinary participation in redesigning the work flow in our ORs. By making clear that the error was, in great measure, a result of systemic problems, all felt a responsibility to be engaged in helping to design the solution.

For over two-and-a half years, the IHI Open School has been using our approach to this case as a teaching tool, simply asking: "What do you think of the way the hospital responded to the error? What should happen next?"

There are now 123 pages of comments on the Open School website, and every day my email forwards several new ones to me. It is clear that this kind of issue raises strong feelings, and it is healthy for the debate to proceed. It may be that there cannot be universally applied principles, that each case is sui generis. But, even if we can get each hospital to consider the question -- before applying punishment --
If our goal is to reduce the likelihood of this kind of error in the future, what is the best course of action? -- then progress will have been made.

Still, I cannot think of Nurse Hiatt without crying, for her, her loved ones, the baby, and the baby's loved ones. Sully said it well, ""I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

22 comments:

@sandymaxey said...

From Twitter:

Culture of Nsg/role of nurses in Healthcare system contribute to this occurring daily. Anachronistic/punitive. Systemic failure.

e-Patient Dave said...

Oh no, no, no, no, NO!!

What a horribly sad story!

I've said many times in my speeches that this "perfection" thing ruins lives. This time it didn't just affect the dead baby & family, and the nurse, it affected the dead nurse's family too.

This is HORRIBLE. Everyone, read the Seattle Times story at Paul's "sad case" link. See how skilled this woman was, and how grief-stricken at the harm her error had caused.

Again I quote Jim Conway: "Merely being extraordinary professionals is not enough to assure perfection, in the absence of *systems*" [like those that Sully cites in aviation] that anticipate and prevent errors.

WE MUST DO BETTER. THIS DID NOT FIX ANYTHING. Nothing is better for patients as a result of this intervention.

(Or, somebody educate me; I know these issues are not simple.)

And of course my heart goes out to the bereaved family of the lost child too. LACK OF GOOD "SULLY SYSTEMS" IS A MAJOR SOURCE OF TERRIBLE HARM.

Pardon me for shouting; my tears as I write this are a pale shadow of the tears of all the people affected by this story.

@jekohler said...

From Twitter:

Don't forget the role the media played in this. Hospital may not punish, but the local news demanded a villain.

Anonymous said...

There was a similar case in my area (not involving a suicide though) where a lab tech drew the wrong patient for blood bank, the patient received the wrong blood and died. Since this is my professional specialty, I know for a fact this was a system problem. The hospital, the dominant one in my area, said to the press the tech was "distraught" and "allowed" her/him to resign.
Thus subtly pointing the finger away from themselves.

In Paul's case the hospital was even more egregious. This MUST stop.

(caveat in the name of evidence-based evaluation: we do not know exactly what the error was, nor whether it involved a willful violation or circumvention of procedure. Nonetheless, it smells to high heaven.)

nonlocal MD

e-Patient Dave said...

I imagine so, @jekohler ... I haven't seen the media coverage other than this story but if it's as you say, it strikes me as hounding someone to their death.

"Hounding" is an apt figure of speech, but "to their death" is literal.

But I HAVE NO INTEREST IN BLAME in this. I WANT US TO FOCUS ON WHAT COULD MAKE ANY DIFFERENCE. Beating on proximal causes never works!!

Pardon my yelling, but we're talking about KILLINGS here. Think of all the tragic tears in this story!

Mark Graban said...

That's just horrible on so many counts, the poor nurse and her family. Firing a person or stripping their license or even throwing them in jail (google Julie Thao or Eric Cropp) does NOTHING to undo the harm to a patient or bring them back from the dead.

@Jekohler is right that our society demands blame and punishment. Sleeping air traffic controllers... forget good human factors design... FIRE SOMEBODY. Now. Bad policy.

Dr. W. Edwards Deming wrote that approximately 94% of quality problems are the fault of the system. Note he didn't say 100%. But still, our gut reflex is to blame when it should be the other way around (assume the system unless proven that it was an individual doing something egregiously intentionally wrong).

To E-Patient Dave - what do you mean by "the perfection thing" killing us? The problem, in my mind, isn't from aiming for perfection... the problem is how leadership reacts when we (the system) doesn't meet perfection. Our response has to be one of learning and improvement, not blame and punishment.

e-Patient Dave said...

A daring suggestion:

I imagine that every good soul involved in this feels horrible. Can anything constructive emerge in the aftermath?

Specifically: might all the parties to this multi-tragedy participate in an IHI Open School analysis, to help others learn?

Bruce said...

It is all too common to blame the individual and ignore the conditions and the structure of the system in which they function.

In the case of most health care organizations, unfortunately it depends more on how much revenue is generated for the institution that determines the punishment (surgeon vs. nurse, for example) rather than addressing the reality that most errors are the result of system problems that are so prevalent in our hospitals. This is the fundamental attribution error described by social psychologists and a major impediment to improving our health care system.

Please keep up the good work supporting patient-centered care.

Anonymous said...

Dave;

Please note that the article says the parties are bound to non-disclosure. Here is another major problem in taking lessons from such errors and sharing them. That is what makes Paul's former hospital's approach so unique.

nonlocal

e-Patient Dave said...

Nonlocal,

And I guess I'm here to say - without trying to be overly dramatic - perhaps this real-life tragedy can have a Romeo and Juliet denouement, in which all involved ask, "Dear God, what have we done?"

This mafia-style "omerta" (silence) tradition perpetuates the harm. I expect nobody involved intended either of these deaths; can we rise above it and find a higher priority than keeping others from finding out what happened??

????

????

Anonymous said...

Dave;

Ask the lawyers. At some point we must rise above self-protection in order to protect others. But lawyers are not hired for that purpose; they have to be overcome. Perhaps Paul can shed some light on how that is done.

nonlocal

Paul Levy said...

In our case, we had disclosed and apologized to the patient for the error. Going public about it did not raise legal issues in that everything had already been discussed with the patient. As a courtesy, we asked the patient if she had any concerns about our going public with the case. She did not, in that she recognized the teaching value of the case. Of course, we protected the patient's confidentiality in the public statements.

Deutschland said...

Great stuff from you, man. Ive read your stuff before and youre just too awesome. I love what youve got here, love what youre saying and the way you say it.

Winnie Tobin said...

Our hearts go out to everyone involved in this case – the parents and family of the baby as well as the nurse and her loved ones. What a horrible tragedy.

While there will be a good amount of discussion about the “systems errors” that may have led to this or any other adverse event, the system fixes invariably involve prevention. Yet, we know that even in the safest of systems, things like this can and do happen. It is not a question of if, but a matter of when.

Emotional support for everyone involved in a med error or bad outcome should be hardwired into the system. It doesn’t appear that the nurse in this case received much support (at least from the hospital administration and her peers), and it’s hard to know if that would have prevented her suicide. But, it certainly couldn’t have hurt.

In terms of the baby’s parents and family, their grief process has just begun. We can be sure that they will need support now and probably moreso in the future when the shock wears off and they try to come to terms with how their child died. Wouldn’t it be nice if emotional support were not just a novel idea, but a routine response to a tragedy like this?

dateless nerd said...

Dear Lord. How incredibly tragic for everyone involved.

As someone who was formerly with the media, I'd like to respond to some of the comments here.

It's true that many of my colleagues tend to focus on the drama rather than the human side of stories like this. But in their defense, the health care industry hasn't been very good about helping the media understand patient safety, the culture of silence, the culture of transparency, system error and so on.

These are complicated issues. Even people within health care don't always agree. So it's perhaps a bit unrealistic to expect the media, who are essentially outsiders, to get it. And don't forget that the media are usually a proxy for the public; if their knowledge about patient safety and just culture is lacking, it's a pretty safe bet that the general public doesn't know much about it either.

Nor does it help when there's no transparency. It's understandable that organizations wish to (and are required to) protect the privacy of everyone involved. But nondisclosure agreements and "no comment" policies can leave so many unanswered questions. Whether hospitals and their lawyers intend it or not, it can give the impression that something is being covered up.

I respectfully suggest that IHI, the NPSF or someone consider designing a training course or an online media kit to help the media better understand some of these issues so their reporting can become more nuanced.

In the interests of full disclosure, I've had personal experience with a medical injury, so perhaps I'm more vested in this issue than others might be. And I would never blame anyone, because that's not what this is about. Holding people's feet to the fire so they're accountable, yes; sacrificing a scapegoat, absolutely not.

Margo Corbett said...

My heart goes out to all who are suffering from this tragdey. It is hard to make sense of any of it.

A Stanford study was done a few years ago on business sytems. One conclusion in the report said it is hard for even the most competent and capable people to do good work in a flawed system. It's a crime that people have to continue to die because media doesn't understand how to report such incidents and hospital executives are afraid to move toward transparency.

I was dropped in a chair by a very overworked nurse ( likely a system problem) after a very invasive surgey. Internal incisions opened and I was left to bleed to death over a holiday weekend. A doctor covering for the oncology service came to me on Sunday afternoon and asked, "Why are you refusing blood transfusios? Don't your realize you are on the verge of cariac arrest?"

I replied, "No one has spoken to me about blood transfusions - get them started immediately."

This nurse and her supervisor treated me terribly until I was released (not a system problem) from the hospital. Their fear led them to lying in my chart about my refusal of a blood transfusion. They were willing to risk my dying rather than do the right thing. When will this type of behavior end?

This was the third medical error I had experienced. I feel God has kept me alive to do the work I am now doing - teaching people how to advocate for themselves and/or a loved one and my new mission of helping medical professionals understand what they can do to encourage patients to take a shared responsibility in their care. I have join the National Speakers Association to further my efforts to get the work out. www.margocorbett.com my bureua-friendly site. Contact information is at www.savvypatienttoolkit.com

Anonymous said...

This accountability is typical. In our health system the Doctors are rewarded for legible handwriting. Nurses are not. Nurses are fired for mistakes. Doctors are not. Additionally, our Doctors have the lowest levels of compliance for handwashing. Our nurses have the highest compliance rates. This is a sad story but our culture will not allow it to be fixed.

gil said...

It is a fact that healthcare providers, and physicians in particular, are more at risk of suicide than the rest of the population.

A study in Oregon found out that 20% of physicians with licenses on suspension committed suicide.

JAMA May 16, 1980, Volume 243, Number 19, 1915-1917

See, Retaliation Against "Disruptive" Physicians - Methods and Strategies - Sham Peer Review

15. The "Game" for the Disruptive Physician Can be Fatal
http://allianceforpatientsafety.org/disruptive.php

According to Stack S., "Physicians were 2.45 times more likely to die of suicide than the rest of the working age population."

Suicide risk among physicians: a multivariate analysis.

Arch Suicide Res. 2004;8(3):287-92., http://www.ncbi.nlm.nih.gov/pubmed/16081394

Paul Levy said...

Lots more comments over at Kevin, MD, who picked up this story.

http://www.kevinmd.com/blog/2011/05/nurses-fired-fatal-medication-errors.html

Paul Levy said...

And over at The Healht Care Blog, which also picked up this post:

http://thehealthcareblog.com/blog/2011/05/02/i-wish-we-were-less-patient/

Dale Ann Micalizzi said...

For the past ten years, following our son's death, I've partnered with various organizations and providers begging for transparency and emotional support for everyone following an adverse medical event. Most of us have focused on the "softer" side of disclosure and apology hoping it would magically take place out of the goodness of one's heart. We were patient. We shared our pain hoping that it would break through the armor. Our efforts have only worked minimally and I am no longer patient on this topic. People are hurting and dying and the powers that be seem to accept this as the way it is. Old time practices don't work anymore. Patients are now empowered to speak up. Soon, employees will be too. Enough apology laws and cozy chats where we put the cart before the horse. Let's fine the facility for negligence and publicly post the fine along with the names of the CEOs and the hospital boards. This will save lives.

As Mark states, "The problem is how leadership reacts when we (the system) doesn't meet perfection." An error occurs and the silence begins. The leadership are the ones that should be held accountable if they aren't going to lead with integrity and provide a safe and honest environment for their patients and staff.

Let's begin a new payment system. You have an error, your plan is in place, you meet multiple times with the family and staff, you report it openly and post it with comments for others to learn from, as Paul did, and you are rewarded with added resources for your facility to further improve quality and systems. If you fail to report or support your patients and employees you are fined and if you continue to be disrespectful to everyone involved in the event and continue to cause further harm, your funding will be discontinued until you do improve. This can be measured.

If a nurse had administered the wrong drug to my son, I'm sure he/she would have ben fired but since an anesthesiologist was involved in the overdose, he was not touched. His attorney was given a supreme court position and the CEO is now leading a multi facility merger. They were all rewarded-not fined. No one learned, no one was accountable and no one suffered except for our family...and perhaps an anesthesiologist and the others present in the OR.

Choose life not death. Seek help if you are feeling lost or abandoned. I have met with many parents who've found their children in their rooms following suicide. Do NOT do this to your family. They need you. There is a better way. Stop being patient and get involved in changing things! Then we can return to the "softer" side of healthcare where the silence no longer perpetuates harm.

gil said...

The world is so small !

One of my friends sent me the following insight regarding this tragic Nurse's suicide and a physician:

"Gil,

The article you sent me earlier about Kimberly Hiatt, R.N. struck a sad chord---she was briefly a client of mine after she was fired by Children's Hospital last year---she hanged herself on April 3. A real tragedy.

I don't know yet what finally drove Kim Hiatt over the edge. She was a fiercely proud professional who made a mistake and was simply devastated. (The 9-month old baby was very sick and awaiting a heart transplant and may not have lived in any event; the parents, though devastated, did NOT blame her!)
The hospital and the nursing commission treated her harshly nonetheless and I suspect she felt a sense of utter hopelessness. She had been unable to find another job, anywhere.

Her case reminds me of a radiologist I represented in New Mexico in 2008.

We WON his case outright before the medical board and he kept his license without any restrictions. But he couldn't find another position.
So in October 2008, he blew his brains out in front of his wife. I was totally bummed out."