This piece just appeared in Beyond Chron
by Suzanne Gordon on October 20, 2014
On Friday October 17, The New York Times ran a story entitled “Controls Poor at Hospital, Nurse Says.” It featured comments by a nurse at Texas Health Presbyterian Hospital in Dallas, the hospital that is now ground zero of concern about the management of Ebola in the US. Registered nurse Briana Aguirre has spoken to the press about her concerns about how hospitals are managing Ebola. To both print and TV media, Aguirre expressed dismay at the hospital’s failure to provide caregivers with protective gear and the training to use it.
This case is a real test of American healthcare’s commitment to patient safety. The issue isn’t only whether hospitals will supply nurses and other healthcare workers with adequate protective gear as the National Nurses United (NNU), nurses’ union has called for. The real test is how Texas Health Presbyterian responds to the fact that Aguirre went public with her concerns.
Call her a whistleblower if you like. What Aguirre is doing is what all those who work in healthcare must have the freedom to do — speak openly about dangers to patients and themselves without fear of retribution. News headlines have trumpeted that Aguirre is “risking her career” by speaking up.
That should not be the case. Nurses, physicians, and all other healthcare workers — no matter at what level of the hierarchy — should be free to express their concerns without worrying about “ending their careers.” This is the only way institutions will learn from their mistakes.
Sadly, in the US, healthcare executives and managers too often give only lip service to the idea that we should end healthcare’s culture of shame and blame and actually support workers who raise critical and inconvenient truths. Many hospital managers don’t support staff who speak up. A 2007 study by prominent University of Pennsylvania nursing workforce researchers Linda Flynn and Linda Aiken of RNs in private sector hospitals in New Jersey found that 42 percent of those surveyed felt their managers would not back them up if they got into a disagreement or conflict with physicians, even if they were right; 43 percent believe their supervisors lacked the skills to manage competently.
Such unresponsiveness often reflects the way hospital managers are themselves managed by higher- level executives. In their performance evaluations, these supervisors are rewarded when staff on their units file fewer “incident reports” –written documentation of problems, mistakes, or near misses that need to be corrected or avoided.
Their bonuses and even continued employment is too often dependent on keeping the lid on complaints, or sloughing them off as unreasonable. While hospitals, like all employers, claim to have an “open door” policy, what I’ve seen in many managers’ offices are admonitions to remain silent in the form of traffic sign-inspired posters declaring that I was entering a “whining free zone.”
A group of prominent healthcare experts and management consultants associated with the Lucian Leape Institute, at the National Patient Safety foundation, issued a report in 2013 condemning the “emotional abuse, bullying, and even threats of physical assault and learning by humiliation [that] are all often accepted as ‘normal’ conditions of the healthcare workplace.”
Their study, entitled “Through the Eyes of the Workforce,” argues that hospital “management practices, expectations, and resource limitations create conditions with major downstream impacts on patient safety, worker safety, and the community.”
Because patient safety experts recognize that the default position in most healthcare institutions is discipline and punish, many are trying to introduce concepts of what is known as “Just Culture” in the nation’s hospitals. Just Culture programs, adopted by a handful of enlightened hospital administrators, are trying to create the kind of “psychological safety” that will encourage workers at any level to raise critical issues or challenge those in higher- level positions without fear of humiliation, reprisal, or firing.
The goal in healthcare should be to allow concerned health care workers – whether physician, nurse, or housekeeper – to identify critical problems that beg to be addressed and act as “problem solvers,” rather than “whistleblowers.” Briana Aguirre should be our first national test of this.
The British National Health Service, which has learned some lessons from a number of bruising scandals, has begun to publicly recognize and reward those in healthcare who draw attention to serious problems. It is recognizing healthcare whistleblowers through the Prime Minister’s New Years Honours List.
We need to do the same. When Aguirre gets out of isolation perhaps President Obama invite her to the White House to thank her for her courage and willingness to risk her career to protect the public.
Just had this published in the Dallas Morning News with my co-editor Ross Koppel of First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety.
Koppel and Gordon: Learn, don’t blame, after Dallas hospital’s Ebola diagnostic failure
Whose fault was it? The doctor’s? The nurse’s? The hospital’s? The patient, for not explaining he had been close to a sick person? The electronic health record’s?
Conflicting reports abound in the press and social media about Texas Health Presbyterian Hospital Dallas’ ER staff failure to correctly diagnose the late Thomas Eric Duncan on his first visit there Sept. 25. The differing accounts have focused mostly on individual, institutional or technological culpability.
First we were told that the nurse in the emergency room hadn’t properly communicated information about the patient’s travel history to physicians. Then we were told that physicians had not read the nurses’ notes that were, in fact, entered into the hospital’s electronic health record. Then we were told that the hospital’s electronic health record would not permit the doctor to read the nurses’ notes.
As the Internet chatter escalates, people continue the blame game. For example, why didn’t the nurse arm-wrestle physicians into paying attention?
While it is too early to determine what precisely happened in this case, it is not too early to consider the critical issues it highlights. One is our health care system’s reliance on computerized technology that is too often unfriendly to clinicians, especially those who work in stressful situations like a crowded emergency room. Then there are physicians’ long-standing failure to pay attention to nurses’ notes. Finally, there is the fact that hospitals often discourage nurses from assertively challenging physicians.
Long promised as the panacea for patient safety errors, electronic health records, in fact, have fragmented information, too often making critical data difficult to find. Often, doctors or nurses must log out of the system they are on and log into another system just to access data needed to treat their patients (with, of course, additional passwords required). Worse, data is frequently labeled in odd ways. For example, the results of a potassium test might be found under “potassium,” “serum potassium level,” “blood tests” or “lab reports.” Frequently, nurses and doctors will see different screen presentations of similar data, making it difficult to collaborate.
Another technological issue is the flatness of electronic records: Much of the information looks the same — a series of boxes to check and pre-formatted text that makes highlighting an urgent or important issue difficult. Electronic records, with their cut-and-paste functions, create what doctors call “chart bloat.” The announcement that Duncan’s electronic records totaled 1,400 pages illustrates this phenomenon. Poor record presentations may well have contributed to the hospital spokeswoman’s initial statement that Duncan’s temperature was only 100.1, when in fact the hospital’s records show it increased from that to 103 by the time Duncan was discharged four hours later.
All of these computer problems probably exacerbated human ones: In their medical training, physicians seldom receive sufficient guidance on the importance of consulting with or soliciting information from nurses. As Claire Fagin, dean emerita of the University of Pennsylvania School of Nursing, has pointed out, physicians are not socialized to consult with bedside nurses and often refer to nursing notes in the most disparaging terms.
Finally, the Dallas case highlights another serious patient safety problem: Many hospitals have disciplined or even fired nurses who try to challenge physician practice. In 2010, two nurses were fired from a hospital in West Texas for submitting an anonymous complaint to the Texas State Board of Medicine about a physician engaging in dangerous and unethical practices in their hospital. Is it any surprise that a nurse practicing in a Dallas hospital would think twice about drawing a reluctant physician’s attention to a patient safety problem?
Duncan’s case is a tragedy reflecting a series of communication failures, both human and technological. These failures go far beyond the Dallas ER. Harm from preventable medical errors is the third-leading cause of death in the U.S. Improving patient safety across the entire health care spectrum will require the construction of medical workplaces where all clinicians can speak up, listen to each other and have health care IT that is responsive to their needs. The issue now is not to blame the staff or the electronic records at Presbyterian but to learn from their mistakes so that we don’t continue to repeat them day after day.
Health care journalist Suzanne Gordon and sociologist Ross Koppel of the University of Pennsylvania are the editors of “First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety” (Cornell University Press). Reach them at email@example.com or firstname.lastname@example.org.
In today’s Science Section of the New York Times, Abigail Zuger writes about the problems of computerized health records and how they contributed to the Ebola Case. Please read her article, which is excellent. Readers who want to know more about these problems should read our book First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety. My co-editor Ross Koppel and his colleagues writes compellingly about the problems of Healthcare HIT. Also read the article in the Dallas Morning News on hospital e-records.
Here is the comment I posted on Zuger’s article.
Electronic medical records also reduce the already limited time physicians, nurses, and other healthcare professionals and workers spend in conversation with each other consulting and planning care. Physicians are now locked into specially constructed rooms huddled over their computers entering data into EHRs. Ditto nurses. People who have never learned to communicate and engage in genuine teamwork and who have never spent enough time communicating about critical medical issues in the past are now even more isolated from one another. So not only do physicians and nurses spend less time actually in conversation with the patient (who seems, sometimes, to be a distraction from the computerized chart), they communicate less with one another. In health professional schools all over the country there is a big push to produce interprofessional education and practice, where healthcare professionals learn with, from, and about each other and consult with each other. Unfortunately, electronic health records and all sorts of other health care information technology is making a mockery of this effort. So once again we are spending billions of dollars and failing to address the crucial problem Zuger identifies. People need to learn how to talk to and with each other and learn from each other. Computers are not making this easier. They are simply exacerbating long-standing problems.
Just published this in
by Suzanne Gordon on October 14, 2014
Iraq war veteran Omar Gonzalez’ recent assault on the White House has led the press and pundits to focus on White House security failures, which, most recently has led to the resignation of Secret Service Director Julia Pearson. Sadly, there has been little effort to consider an equally pressing security problem the Gonzalez case highlights – one that will not be touched by efforts to enhance White House security. These are the problems that thousands of communities cope with due to the complex mental health problems of soldiers returning from America’s recent wars Middle Eastern wars.
Most veterans who suffer from combat related mental illness do not end up leading a charge against the President. But literally thousands of them return from war badly damaged by a constellation of mental and physical illness that present problems for their own health and well-being as well as that of their families and communities. Even though, these problems have been widely publicized, many families, friends and neighbors of veterans ( as well as veterans themselves )still do not understand the fighting, alcohol or drug abuse, and out of control rage their loved ones exhibit is, in fact, far more than machismo on steroids. As Erin Finley has explained in her book Field of Combat: Understanding PTSD in Veterans of Iraq and Afghanistan, (http://www.cornellpress.cornell.edu/book/?GCOI=80140100613100 ),they do not understand that these behaviors may be signs of mental illness that can be treated and managed. Nor do enough of them know that hundreds of hospitals and clinics at the Veterans Health Administration have programs that specialize in these problems, can offer significant expertise and help that is far superior, when it comes to combat related mental illness, than is available in the private sector. http://www.ptsd.va.gov/
Tragically, the media’s recent focus on the problems in the VHA system may have made things worse. The drumbeat of media reports about the “scandal ridden,” VA have painted such a bleak picture of the nation’s largest – in fact, only – integrated healthcare system, that many Veterans and their families may now conclude that they cannot access any VHA programs at all. Some are convinced that the system is too broken to offer help. In the course of gathering information for a book I am writing on the VHA, I have talked to dozens of people who, when they hear about the project, wonder why I would want to write anything about a system that is so hopelessly flawed and which, they have been led to believ, is almost beyond repair. When I explain that the VA is actually alive and well and has amazing programs that help Vets – particularly those with mental health problems, they are invariably surprised.
Again media coverage one of the right’s silver bullet for Vets — allowing them to get help from private sector providers may make matters even worse for those veterans who have mental health problems.
An estimated 30 % of returning soldiers suffer from Post Traumatic Stress Disorder (PTSD.) Since the wars in Iraq and Afghanistan, others have had traumatic brain injuries that produce what is known as Post Concussive Syndrome (whose symptoms often mimic those of PTSD). Many Iraq and Afghanistan veterans suffer from both PTSD and PCS. Ever since the Vietnam War pioneering psychiatrists, psychologists, social workers, nurses and others in The Veterans Health Administration have worked diligently to pioneer treatments for PTSD and other combat related mental illnesses. VA mental health professionals have developed expertise in Cognitive Processing therapy, Prolonged Exposure Therapy, and have both out patient and in patient programs to deal with this potentially crippling problem. The VA’s work on post concussive syndrome is also unparalleled. And the VA’s mental health professionals know how to distinguish the one from the other and treat both.
Few private sector psychiatrists, psychologists and social workers have this kind expertise when dealing with PTSD or many of the other problems that are specific to this population of patients. In fact, VA psychiatrists have told me that mental health professionals in the private sector often prescribe drugs and treatments that make matters worse not better. Even those who have experience with victims of rape or other trauma, may not understand specific component of combat related PTSD. Many veterans with PTSD don’t only suffer because of what was done to them – but from what they did to others. As one VA psychiatrist recently explained to me, soldiers in the heat of battle may have killed civilians, or children or even their own buddies in friendly fire. This is not the typical presentation of patients who community psychiatrists, psychologists or social worker normally see.
As news of Omar Gonzalez’s dramatic assault fades from the front page, it is important not to forget that the problems veterans and their families face day in and day out. Many of these problems are treatable and manageable – with help that they can get from a system that, like the diseases it treats, is too often maligned and misunderstood.
Please read this story in the New York Times “Detailing Financial Links of Doctors to Drug Makers. ”
We’ve all got to start protesting this kind of corruption of healthcare. What this means is that patients can’t trust what their doctor is telling them. Jerome Kassier wrote about this problem in his fabulous book On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health, and it isn’t getting much better. You cannot trust what your doctor prescribes as treatment because you don’t know if he/she is prescribing it because he/she is financialy benefiting from it or because it’s necessary. Doctors are being perverted and converted to drug company shills. We know, for example, that psychiatrists have been prescribing dangerous and unnecessary meds for children. According to Medscape’s Physician Compensation Report , physicians earned, in 2014, on average between $174,000 (HIV or Family Medicine MD and $414,000 (orthopedist) a year. Yet apparently some feel they need an extra $500,000 from a drug company to make it in life. Even though these doctors do no represent all doctors, they pervert the process of treatment because they are the ones drug companies hire or influence to write articles and give speeches promoting problematic or unnecessary treatments. This process of influence peddling negatively influences the judgment of honest physicians. And it subjects patients to unnecessary procedures and ineffective treatments that jeopardize their health.
Tragically new categories of providers are entering the influence peddling game, including NPs, PAs and some RNs. Some of them are also on the take because drug companies have discovered that many of them will accept pharmaceutical money. They may not get as much as physicians but there is plenty of influence peddling going on in nursing. Plus, NPs and PAs get information from the same compromised sources — journal articles written by physicians On the Take. Everyone should read Jerome Kassirer’s book of the same title On the Take. And Richard Deyo’s new book about the back pain industry Watch Your Back which we just published at our Cornell series. I will do another blog on Rick’s book shortly.