Wednesday, October 24, 2012

"Bad apples" don't fall far from the tree

A distinguished and thoughtful colleague asks, "Now, what do you do with this bad apple?"  The story on Medical Daily is "Nurse Who Injected Elderly Patient With a Lethal Dose of Coffee and Milk Says 'Anyone Can Get Confused.'"  An excerpt:

A student nurse who accidentally injected coffee into the veins of an 80-year-old female patient who died hours later has defended herself on broadcast television by saying that "anyone can get confused."

Rejane Moreira Telles said that she had just three days of work experience in a Rio de Janeiro clinic when she botched up administering a drip to Palmerina Pires Ribeiro, who died hours after she had coffee mixed with milk injected straight into her body.

The 23-year-old appeared on Brazilian TV Globo's Fantastico where she told reporters that she was aware of the risk of administering an intravenous feed. However, the novice nurse added that "anyone can get confused."

"As they [the feed and blood drips] were next to each other, anyone can get confused. I injected the coffee and I put it in the wrong place," Telles told the TV station.

I replied:

"Ask this question:  Could it have happened to anybody in that situation?  From the description of her lack of training, plus the adjacency of substances, I would guess the answer is yes."

So, to turn again to my colleague, I have also to ask. "Who's the bad apple? The nurse, or the people who were supposed to make sure she was trained."  As a great basketball coach, John Wooden, once said, "You haven't taught them if they haven't learned."

Telles has now been indicted for involuntary manslaughter.  Should her life be ruined now?  Should it instead be the head of training for nurses in that facility?  The CEO?

Or should everyone there get a lesson in how to detect systemic problems and fix them?  Apportioning blame is generally a useless path.  Better to be hard on the problem and soft on the people.


Paul Levy said...

From Facebook:

Isabel: I am not getting a clear picture of the story. The only way I can think of coffee with milk getting into someone's IV is if someone draws it up into a syringe and injects it directly, or pours it into a drip bag from a cup ("half a glass" worth, according to the witness), hooks it up to a line, and hooks the line up to the IV cannula. Neither mechanism sounds involuntary to me. How do we know she's not a disingenuous psychopath trying to deflect blame onto her professional inexperience?

Teresa: Yes. Some sort of appropriate punishment.

Jennifer: I have been to Brazil, Rio DeJaneiro. I've looked at the outsides of their "hospitals'". This does not surprise me. She should be held accountable under the licensing regulations that are expected to be upheld for licensed nurses down there. What are those regs anyway? People use the term "nurse" interchangably. A true "nurse" is a licensed individual held accountable by practice standards under the governing licensing board, and in MA most gave at LEAST a four year college degree in science.

Marilyn said...

From Facebook:

As a nurse, I honestly don't understand how anyone calling herself a "nurse" , even a student nurse, could make this mistake. The training may be lacking but this individual is clearly negligent and culpable, by any standards.

Paul Levy said...

Ok, for the sake of argument, let's say she was not competent. What does it say about the institution or her supervisors that no one would have recognized that and either (1) provided remedial training or (2) removed her from a position of taking care of patients? Should we expect the student in this situation to know she is not competent?

Jason said...

Paul, I honestly think that one of the things that makes me a good practitioner is the recognition when I am not equipped to handle a given situation. I don't worry about people who don't know things, I worry about the people who don't know they don't know things. I am a nurse, and I've had bad days at work where my safety margin was not all it should be, and I can not come up with a single scenario that excuses this horrifying lapse of judgement. Was there an institutional failure? Absolutely. But the death of the patient is 100% her fault and her fault alone.

Paul Levy said...

Thanks, Jason. I think you are understandably applying standards of education and care from a more sophisticated environment to a geographic area and cultural situation that might be quite different. Check my new post above this one for an example from the US, and see what you think about it.

Morgan Rose said...

She's likely the victim of a situation that I've encountered in working with novice employees. It sounds like this patient may have been receiving trickle feeding via a kangaroo bag/drip attached to a feeding tube. I've seen these bags hung immediately adjacent to IV infusions. My suspicion is that in attaching both the enteral and parenteral infusion bags, there was no safety system in place to prevent the enteral drip set being attached to an intravenous catheter, especially if they're not using infusion pumps. I've watched a new employee struggle to sort out which line is attached to which patient port, often with near misses.
Yes, it's a terrible mistake. She's doing the right thing and admitting responsibility. She's also probably beating herself up far more than any of us could imagine.

Marilyn said...

From Facebook:

there is shared culpability even beyond the student and the institution. I once taught nursing school in the US. While many of the students were excellent, a few were less than mediocre, illiterate even. How did they even get into nursing school, I wondered. I felt a responsibility to Society not to pass them along to do potential harm to sick and vulnerable patients. But there was pushback, both from the students who paid their tuition and expected a diploma for their investment, and the educational institution who admitted them. Just because a person wants to be a Nurse doesn't mean they should be one.

David Reinertson said...

I agree with Ms. Rose. Most people can't imagine how this could happen.
Therefore, some nurses are never told, never imagine, and have to discover on their own that i.v. tubing and feeding tubing have a deadly similarity.
New nurses should be told of these "nightmare scenarios" carefully, since their anxiety level is usually above optimal anyway. Nevertheless, the nurse instructor lives in fear of this kind of thing happening to one of her students.
One way to frame this is to ask the student to list the reasons for and dangers of each procedure before demonstrating it. By the end of a year, it becomes a habit of caution.
By the way, there's now a technical solution to this not-uncommon-enough error. You can buy feeding-only syringes which don't fit onto standard i.v. tubing. Of course, teaching people to use brown feeding syringes may not be any more effective than teaching them to check and identify the business end of the tubing.

David Reinertson said...

The error is not uncommon enough. Most nurses can't imagine this ever happening.
Therefore, do we teach it?

Nurse instructors probably have a nightmare bag of such horrible scenarios. To tell these tales too often would either raise the students' anxiety to a panic level, or risk numbing their alertness to the unexpected.

One way to teach safety is to have the student think of and say all the reasons for and dangers of each procedure before demonstrating it. After a year or two of this in clinical, she will have a habit of caution.

By the way, you can buy brown feeding-only syringes, which don't fit onto the i.v. tubing. Is it safer to teach use of the brown syringes than to teach checking the far end of the tube before using it? Who can say?