Death by disrespect
October 2010 -- The cover story in this month's Reader's Digest offers a fairly strong look at hospital errors, relying mainly on short personal essays by five health professionals. Three are physicians, and the feature has other physician-centric elements, including the title on the magazine's cover, "Doctors Confess Their Fatal Mistakes." But the final essay is by nurse Sunnie Bell, who gives a powerful account of how a patient died because a physician ignored Bell's warnings. Bell then urges several specific improvements in nurses' working conditions. Her essay vividly illustrates how disrespect for nursing can kill, and it at least suggests the role nurses should play as patient advocates. Another piece, a sad story by a pharmacist who was criminally prosecuted for a deadly error, also shows that physicians are not the only health professionals whose work matters. One of the physician pieces is by Johns Hopkins's Peter Pronovost, a health care errors expert who has become well known for his efforts to promote the use of checklists and other safety measures. Pronovost makes a point, as he often does, to include nursing empowerment as a key element of reform. And a sidebar with short descriptions of some new patient safety ideas includes one about Boston's Brigham and Women's Hospital, where "WalkRounds" are done by "senior executives," a category that reportedly includes the chief nursing officer! Some publications would have mentioned only the CEO and the chief of medicine. Unfortunately, an essay by University of California San Francisco physician Robert Wachter indicates a distressing lack of awareness of the role nurses play in monitoring patient conditions and in hospital care generally, as the author attributes a failure to detect an impending pulmonary embolism 30 years ago solely to himself (as a second year medical student) and the hierarchy of physicians on duty. On the whole, though, Joe Kita's cover story includes nursing to an extent that is unusual for such an influential publication. We commend him and Reader's Digest.
The 12-page feature's general introductory material is somewhat more inclusive of nurses than the magazine cover. The table of contents describes the article, "White Coat Confessions," this way: "Doctors, nurses, and pharmacists hold your life in their hands. Here, their shocking stories of what can go wrong--and what must change to keep us safe." Of course, it's far from widely understood that nurses are among those who hold patients' lives in their hands, so this is helpful. The feature begins with a short introduction by Kita, who briefly explains the prevalence of hospital errors. As an example, Kita uses a diagnostic error by one of the physician essayists, University of Nevada ED physician Bryan Bledsoe. And Kita relies on Pronovost for expert input on the need to talk about the errors problem despite practitioners' fear of doing so. This part of the feature gives the general impression that physician errors are what matter, and that we need better systems to prevent them. However, Kita does at least note that the traditional reluctance to admit errors is changing because "doctors, nurses, and pharmacists" all stepped forward for this piece to say "I'm sorry," and more importantly to address the flawed systems that make the errors possible.
The material preceding Sunnie Bell's essay has some good elements for nursing. The most helpful part is Pronovost's essay, which describes an error he made as a young physician, during a 36-hour shift, when he felt he needed to discharge patients from a critical care ward to make room for others. He decided to move a patient who had had esophageal surgery to another ward and to remove his breathing tube. But the patient's breathing sped up and his oxygen levels dropped, so the tube had to go back in. However, as it turned out, the patient's throat was severely swollen from the surgery. So Pronovost was unable to get the tube back in quickly enough. There was a real risk of brain damage because of the medication given to stop the patient's breathing during the process. Pronovost was distraught, telling the patient's wife what had happened, though not that it was the "wrong decision" to remove the tube in the first place. Fortunately, the patient eventually regained consciousness--many stressful hours later--and recovered, but Pronovost still remembers his great relief.
Pronovost goes on to discuss why things like that happen and what can be done. He explains:
Doctors, especially Johns Hopkins doctors, didn't make mistakes. If you did, you suffered your shame silently.
He also notes that it's "important to us to believe in the myth that doctors are perfect." Pronovost argues that many "medical errors" happen because hospitals lack standardized checklists for common procedures, as airline pilots and NASCAR teams have. He says that to remove that breathing tube, he should have had to go through a checklist including getting "input from the patient's senior physician and nurse." If anyone disagreed, he would have been stopped. "A simple system like this not only protects patients but also promotes honesty, respect, and teamwork among hospital staff." He notes that a few years ago he helped develop a five-step list for insertion of a catheter near the heart for "doctors and nurses" in more than a hundred Michigan ICUs. In 18 months it lowered the rate of catheter infection by 66 per cent and saved 1,500 lives.
Pronovost's focus on empowering nurses to protect patients is commendable. His suggestion that nurses should be able to stop physicians from doing procedures the nurses believe will harm patients is hardly the traditional physician view. Underlying Pronovost's view is his recognition that physicians are not "perfect," and that they make mistakes that nurses (not just more senior physicians) can catch. When was the last time House or Grey's Anatomy showed a nurse catching a life-threatening physician error, though that happens many times every day in the real world? And Pronovost's emphasis on "honesty, respect, and teamwork among hospital staff" is great as well, though it might sound like simple common sense to outsiders. In fact, this kind of reform would not only benefit patients in an immediate way, but also help to resolve the nursing shortage and associated under-staffing. If nurses were treated with more respect generally, their working conditions and emotional wellbeing would improve, they would be less likely to flee the bedside, and decision-makers would be more likely to give nurses the resources they need to do their jobs.
As much as we generally appreciate Pronovost's message, though, we're always a little sad that the way his views are presented in the media gives the impression that nurses protecting and advocating for patients is something that he came up with. In fact, patient advocacy has been central to nursing since the beginning, and nurses don't need to be (or should not need to be) told that is their job. It was a nurse's job way back then to stop Pronovost from removing the breathing tube. Of course, this is all consistent with Pronovost's basic message of reform. We might say that it has always been nurses' job to do these things, now let's give them the practical power to actually do them.
The essay by Eric Cropp, the pharmacist, only touches on nursing indirectly. Cropp describes a day when he was practicing at Rainbow Babies & Children's Hospital in Cleveland. At the time he had 14 years of experience, but because he was very busy, he "made the mistake of not thoroughly checking a saline-solution base that a technician had prepared for a child's chemotherapy treatment." She mixed it more than 20 times stronger than ordered. Cropp explains that when a nurse gave it, the high concentration made a two-year-old girl's brain swell and put her in a coma; three days later she died. Cropp was convicted of involuntary manslaughter, got six months in jail, house arrest, probation, a fine, and 400 hours of community service. He says he lost his license, career, reputation and confidence--and the worst is that he has to live with the memory of the little girl.
Cropp accepts responsibility, but also suggests reforms to prevent future tragedies, specifically better training for pharmacy techs, better technology to reduce the number of similar medication packages, the use of bar-code systems, and better working conditions, including less crowding, better lighting, and a reduced workload. He also wonders what would have happened if he had told the family he was sorry right away, which he was advised against doing. He says that "doctors, nurses, pharmacists, and others" should be able to confess their errors, be supported, and work to make the system better. The description at the end of Cropp's essay notes only that he is currently unemployed.
Nursing is at the periphery of this story, but much of it is very relevant to nursing, and readers might not get that. Cropp notes that it was the nurse who actually gave the solution, but he makes no suggestion that the error had anything to do with that nurse. It's possible that the package was labeled with the super-high dose, in which case the nurse should have caught the error. But if it was labeled with the intended dose, not the actual dose, the nurse had no way to know that the solution being infused had been made incorrectly. Nurses have a responsibility to do what is within their power and scope of practice to prevent medication errors--they are the last line of defense before medications get to the patient--and some of Cropp's proposed reforms would benefit nurses greatly. In particular, using technology to reduce the number of similar packages and implement bar code systems could greatly reduce the risk of error. And better working conditions are also critical, including the reduced workload Cropp urges for pharmacies. Indeed, these were reportedly all factors in the fatal error that Wisconsin nurse Julie Thao made in 2006 in giving a patient a medication incorrectly. And Cropp's inclusion of nurses as members of the health care team is also welcome. Indeed, Readers Digest's inclusion of Cropp shows that health care requires a team, rather than simply a collection of little people who help physicians, which is how the media often presents health care.
However, Robert M. Wachter's account of his experience as a second year University of Pennsylvania medical student 30 years ago is troubling. Wachter tells about one time that he was on rounds at a VA hospital. He says the "team" on rounds was an attending physician, a resident ("the real boss"), and two interns who were as "green" as Wachter was. Wachter says that during a "pre-round" with one of the interns, he found that a 71-year-old patient who had just had a hip operation was sweating and panting. Wachter checked the man's vital signs, and ruled out breathing problems, heart failure, and pneumonia. So Wachter attributed the patient's condition to the hot room, and told him that the team would be by in a few hours. Before long the patient coded. Wachter says the resident began CPR and yelled to Wachter about what the patient had looked like earlier. Wachter "lied" that he had been a little bit short of breath but okay. Actually the patient had had a massive pulmonary embolism. Wachter notes that the patient had displayed "textbook" symptoms, but Wachter had not read that part of the textbook yet, and he "was too scared, insecure, and proud to ask a real doctor for help."
Wachter notes that the same medical education system exists today, and he wonders how many patients have died or suffered harm "at the hands of students as naïve" as he was. He urges "teamwork training" for medical students and residents that stresses the importance of "speaking up when they see something they don't understand." He also says students should have exercises to help them recognize common clinical conditions before they get on the wards, and attendings should be better trained in up-to-date clinical care and in supervising others.
We suppose it's possible that Wachter is just omitting nursing in a misguided effort to be polite, but it seems far more likely that he does not understand the central role nurses actually play in the care he describes. Nurses are the health professionals whose job it is to monitor patient conditions for changes like this and take appropriate action. If Wachter the medical student had brought the patient's condition to the attention of one of these actual health professionals, the patient might have lived. Does Wachter know that, even today? And frankly it seems unlikely that Wachter would have been the first one to pick up on the symptoms in the first place. Was it the nurse who identified the shortness of breath, reported it to other staff, and initiated the code? Weren't nurses involved here at all, even as part of the code? Or is it just that only the physicians mattered? To Wachter, the "team" apparently consisted only of physicians. Yet this patient's problem was at least as much a nursing problem as anything else. So the patient did not die at Wachter's "hands" any more than at the hands of the nurses. And these symptoms were not subtle or obscure.
Likewise, Wachter's prescriptions for reform suggest that he views serious care as entirely a physician concern. His proposed improvements seem to relate only to physician conduct. We suppose it is possible that the physician "teamwork training" would include something about "speaking up" to and working with the health professionals who actually provide most of the skilled care hospital patients get, including monitoring them for changes like this. But since the piece is all about his failure to ask a "real doctor," we doubt it.
Of course, an "insecure" and "proud" medical student might not want to ask a nurse about a problem like this any more than he'd want to ask the physicians, for fear of admitting that the nurse knew more about it than he did. And in fairness, the nurse might have abused the student, as some do, as a way to strike back at one weak point in a group that often shows disrespect for nurses. But the failure to recognize the role nurses should and do play here, along with the clear implication that physicians alone provide the skilled care this patient needed, is hard to justify.
The feature also includes a kind of sidebar titled "Patient Safety: 5 Fresh Ideas." These include measures to offer flat-rate procedures with a 90-day "warranty" to provide an extra incentive to avoid errors; the use of "video auditing" to improve compliance with hand-washing procedure; and the use of simulation centers that use "computerized mannequins" to teach "medical professionals-in-training," which presumably might include nurses. Another item, under the heading "Take a Walk," explains that at Brigham and Women's Hospital in Boston, "senior executives"--meaning the president, CEO, and "chief medical or nursing officers"--do weekly "WalkRounds" to "emphasize safety and listen as staffers discuss concerns." The item says that these have been shown to "change behavior." It may seem like a small thing, but we commend the magazine for mentioning the chief nursing officer, which tells readers that there is such an "executive" and at least suggests that nursing is on a par with medicine in clinical importance. And the item "Scan it" says that to reduce medication errors,
nurses at Parkview Medical Center in Pueblo, Colorado, carry small bar-code scanners that read patient wristbands and link wirelessly to pharmacy and doctor records to ensure that the right medication is given at the right time and in the right dose. The error rate has dropped by more than half.
That sounds great, though it might not address errors by the physicians or pharmacists. Indeed, it might be possible to read this as suggesting that once nurses are doing what physicians want, they won't be making any errors, if the remainder of the feature did not disprove that. Of course, it is nurses' professional obligation not to give whatever medication physicians request without question, but to make an independent assessment of whether the medication is appropriate for the patient. And giving the right medication in the right dose to the right patient has always been a key focus of nurses' clinical practice; it's not something that this "Scan it" system suddenly came up with.
Calling Dr. X
The last of the five essays is by "Sunnie Bell, RN," who is "a Certified Diabetes Educator and was National Diabetes Educator of the Year in 1995." Bell describes an evening when she was practicing as a hospital nurse, and a "highly regarded" physician refused to consider emergency surgery for a patient with a suspected bowel obstruction, despite Bell's repeated phone calls to him at home. The essay's headline is a telling exchange between patient and nurse:
She whispered, 'When is my doctor coming?' 'Soon,' I lied.
That headline may suggest that the most important thing nurses do is get physicians. Of course, that is one thing nurses do, since physicians do have specialized knowledge some patients may need, and in this case it appears to be have been one thing that was required to save the patient's life.
Bell explains that she was the "nurse in charge of the evening shift at a small hospital." She notes that she was "enthusiastic and experienced--a top graduate of a prominent nursing school," which conveys that "top graduates" and "prominent schools" exist in nursing. Bell says that one 85-year-old patient, for whom she uses the pseudonym Mrs. Owen, had been "admitted by Dr. X, her longtime family physician, because she had a suspected bowel obstruction. She was alone." Bell says that the patient's condition quickly deteriorated, with increasing pain, and Bell became convinced that she needed emergency surgery because "obstructions can be deadly."
I called Dr. X at home immediately. He was a highly regarded doctor, and his photo was displayed in the lobby along with those of the hospital's other physicians. I passed it every day on my way to work. But despite my concern, Dr. X said surgery could wait until the morning. He told me to increase her pain medication, but the drugs didn't help, nor did anything else I tried. Over the next five hours, I called Dr. X three more times, asking that he come to see her or at least call in a consulting physician. I always got the same instructions delivered in an ever more irritated way. And because nurses never questioned doctors, I bit my lip and followed orders. Toward the end of my shift, Mrs. Owen was so weakened by her pain she could barely speak. She motioned me over to her bed and whispered, "When is my doctor coming?" "Soon," I lied. That word has echoed in my head for quite some time. Mrs. Owen died the next morning. Whether she had a heart attack, stroke, or ruptured colon, we'll never know, because an autopsy was never ordered. Dr. X completed the paperwork just as if he'd done everything right, and no one questioned him.
But Bell admits that she could have questioned him, noting that she "could have submitted a report, carefully documented and supported by my supervising nurse." She implies that she did not because "challenging a doctor may not get a nurse fired, but it'll often get her or him publicly chastised, reassigned to a different floor, or moved to the graveyard shift." She explains that
this is more than a complaint against one man--bullying and disrespect occur every day in every hospital throughout America. Most of the time the behavior is petty and hurts only the workers involved, but sometimes, as I witnessed firsthand, it can take the life of an innocent person.
Bell doesn't limit her recommendations for reform to the obvious. Instead, she argues that "hospital patient-to-nurse ratios sometimes get too high to keep people safe," and that the shortage of nurses is really "just a shortage of nurses who are willing to work under current hospital conditions. More respect will bring them back." She is suggesting that the kind of disrespect Dr. X displayed is a significant factor in the shortage, presumably not only because it leads to nurse burnout and turnover--no one wants to work in that atmosphere--but also because disrespect leads decision-makers to allocate too few resources to nurses. In that sense, then, it does not "hurt only the workers involved," but all workers and patients. Bell also recommends "whistle-blower protections to safeguard nurses who speak up for the safety of patients," and says that with those, "I wouldn't have thought twice about challenging Dr. X." She concludes:
Each nurse must take it upon herself or himself to stand up to and report physician intimidation and abuse. Nurses are not second-class citizens in the health care system. In fact, in the increasingly busy and sometimes heartless hospital world, we are the patient's primary protector.
Bell's story and her essential points are tremendously helpful messages to place in one of the most widely read magazines in the world. She gives a clear, concise account of one significant type of deadly health care error--the error that occurs because physicians disrespect nurses and ignore their expertise. She does not address specifically why physicians act that way, which would involve examining the widespread ignorance of the value of nursing, among other things. But she does at least suggest why physicians get away with it: Physicians as a class enjoy too much power and prestige (with their noble visages plastered across the hospital walls), so they can operate with relative impunity; they can often, to borrow a phrase, bury their mistakes; and they can retaliate against nurses who question their actions.
Bell's proposals for reform are sound. And she even manages to work in a reference to patient advocacy at the end, though it probably will not be clear to readers that nurses are not just the patient's "primary protector" because hospitals are "increasingly busy and sometimes heartless," but because that role has always been at the core of nursing. Challenging people like Dr. X is not just something that nurses should be empowered to do if they wish; it is and always has been a central ethical requirement of nursing. Doing it in the real world, of course, is something else. But nurses have done it, and some even did it 20 or 30 years ago. Bell might have noted that, though her own reluctance to act is understandable.
Other aspects of the piece might also have benefited from further explanation. We were a little troubled by Bell's statement that "because nurses never questioned doctors, I bit my lip and followed orders." Bell places this in the past tense, but it's not clear when the incident occurred, so we're not sure if she's saying this is the way it still is. If her story is from 20 or 30 years ago, does she think things have changed? And again, even in the past, it's not correct to say that nurses "never" questioned physicians, though Bell certainly is correct in her account of the abuses of power that could happen if a nurse did speak up. Bell also seems to suggest that her challenging of Dr. X would have taken the form of an after-the-fact protest. That might help future patients, but not Mrs. Owen. What was needed here was for Bell and her manager to go around or above Dr. X to a physician or ethics committee member who could help them save Mrs. Owen. Lastly, while we do not really expect Bell to avoid the term "orders" when most nurses themselves still use it, we have to point out that using that term, instead of "prescriptions," "care plans" or something similar, reinforces the idea that nurses really cannot and should not question physicians. Nurses are not physician subordinates, and they do not carry out physician "orders." (See our FAQ on "orders.")
On the whole, though, Bell's essay is powerful and effective, and we thank her and Reader's Digest for publishing it.
See the piece "Doctors Confess Their Fatal Mistakes" by Joe Kita, published in the Reader's Digest, October 2010.