I’ve Been Thinking about nurses, horses, guns, and hugs

I’ve been thinking about nurses, horses, guns, and hugs.

We all were infuriated when we read about the man last March who walked into a Georgia hospital and shot a nurse he blamed for his mother’s death. How could anyone do such a thing? Then I recalled a phrase from the Bible commenting on the human penchant for passing judgment on others while we do the very same things. (Romans 2:3)

Hardly anyone barges into hospitals like the man the AP article described as “armed with a three-year grudge and more guns than he could hold.” But with nurses who have been involved in unintentional medication errors, do we “shoot our wounded?” We used guns of blame, with bullets of shame, and charges of felony in the case of Julie Thao, RN, of Madison, WI.

Last week at The unSUMMIT for Bedside Barcoding, I had the privilege of interviewing Julie, who in the summer of 2006 mistakenly administered a drug via the wrong route to a 16-year-old mother in labor, causing the patient’s death. Dr. Charles Denham, founder and director of the Texas Medical Institute of Technology, was with us for the interview.

Mark: How did you feel?

Julie: I don’t mean to diminish the incredible, tragic loss of my patient, but there was more than one death that day. Everything—all of who I was—died.

Charles: Julie literally collapsed on the floor. When caregivers are swept into events of unintentional harm, they become patients immediately. They suffer a post-traumatic stress syndrome. Suicide, divorce, depression, and a whole host of cascading problems occur.

We talked about what went wrong. Look-alike mini-bags, common connectors, failure of a new bar-coding system, compensatory formalized work-arounds, and fatigue combined to result in simple, human-performance error.

On the Fourth of July, Julie signed up for a second shift to cover for a coworker who had a family event. Following the double shift, Julie slept at the hospital because she was so fatigued, then worked a third shift to help alleviate the staff shortage.

Charles: We know from the studies on fatigue that she was the equivalent of being intoxicated. Human-factors research on fatigue shows that after the end of just one shift, a nurse will make three times the repetitive errors than she would at the beginning of a shift.

So, I asked Julie why she volunteered? She told how nurses love what they do and how by nature they respond to requests for help.

Julie: That’s why we do what we do. “Please help” is like hitting your knee; your leg goes up. When you put your name on the sign-up sheet and the manager puts a smiley face and “thank you” beside your name, and all your coworkers see that—why does that feel so good?

The next day, I was pondering all this while watching the news about Eight Belles—runner-up of Kentucky Derby 134—falling just past the finish line after breaking both ankles. While vets euthanized the filly where she lay on the track, blogs were burning the ethers questioning the ethics of pushing thoroughbreds beyond their limits to snag purses for their owners and garlands for themselves.

We won’t let pilots fly, or truckers drive beyond their limits, yet we push our nurses to the point of exhaustion and error only to ditch them in their time of need.

When Julie, who had helped develop her hospital’s bereavement program, returned for pastoral care she was ordered off the premises. Her colleagues had to console her out on the sidewalk.

Charles: She was abandoned at the worst possible time. That is cruel.

It all seems more hypocritical than Hippocratic to me. “With regard to diseases,” wrote the venerable Greek physician, “make a habit of two things—to help, or at least to do no harm.” (Epidemics, Bk. I, Sect. XI) To not help nurses at their point of need is to shoot them.

So I asked my guests what a hospital’s to do with nurses when they are involved in errors? Chuck and Julie responded by walking us through a landmark article on which they corroborated, entitled, “TRUST: The 5 Rights of the Second Victim”. I urge you to download, read, and send it to your colleagues, C suites, and board members.

And what’s a nurse to do when she is supposed to go home but only half of a shift shows up, and her coworkers beseech her to stay and ask, “Who is going to take care of the patients?”

Julie: The very best answer to use from now on is “I am—I am going to take care of those patients by going home and not taking care of them when I am exhausted and putting them at risk.

Remember the setting of this interview—The unSUMMIT for Bedside Barcoding. Understandably, I had to ask: What do you think about the point-of-care bar-code technology? Could it have saved your patient’s life?

Julie: Yes, in all honesty, if it were working correctly. Those of you who are waiting for the research, wondering if there is enough evidence that bar coding works, I think there’s enough evidence of what happens when you don’t have it. Yes, I do believe it could have saved my patient’s life.

But Julie was not finished. She affirmed The unSUMMIT’s conviction that while bar coding is the right thing to do; it must be done the right way. Julie helpful advice is offered in my postscript below.

The late Henri Nouwen’s coined the term “the wounded healer” by which he referred to ministers who allow their wounds to become a major source of healing power. Julie is a wounded healer giving her life to nurses who have walked their wards in her shoes. She brings comfort to families who have experienced the loss of loved ones to medication errors. And, in spite of attempts to ban her from nursing, Julie continues her profession as a certified patient-safety officer by helping caregivers to avoid medication errors and hospitals to respond properly when errors occur.

What are we to do? I recently saw a faded bumper sticker: “Hug a Nurse.” Reminds me of the Detroit Police Department’s campaign calling for “Hugs not bullets.” Is there a nurse you could shoot an e-mail, slip a note, or text message to in the next few minutes—sealed with hug? I suppose one could argue that there’s no harm in silence. Then again…

What do you think?

Mark Neuenschwander
mark@hospitalrx.com

PS: Advice from Julie Thao to hospitals considering bar coding at the point of care

• Be willing to say that the cost of a bar-coding system is just part of it

• Dedicate the cost of making a comprehensive training program

• Learn from the frontline users how you need to design the training and implementation processes for their units

• You cannot afford to spend the least amount of money in the shortest amount of education time

• The way bar coding is presented to your staff will greatly influence whether or not you are going to have resistance

• Sell them on its value

• Bring someone in who can tell a story of what barcoding will do for their units

Copyright 2008 The Neuenschwander Company