Bring out the scapegoat

It has been quite the week here in paradise. I really need to work on developing the aresolized ativan room spray – although what I would really like is some sort of spray that increases the self-awareness of the HUA syndrome.

Healthcare is always an interesting field to observe, for it is made up of people. People at their absolute best, people at their absolute worst and all shades in between. Tying those people together in a sticky web is the culture of the place, which can and often does mires us in immobility and a sense of victimhood.

I’ve thought quite a bit this week about Kimberly Hiatt, the nurse from Seattle who killed herself following the tragic medication error where she administered too much Calcium Chloride to her patient, an infant in the NICU. So many things are disturbing about this event and yes, it is awful and should not have happened that the child died, but the aftermath of that event provides us a very good window into seeing how it could have happened.

A google search of the news around these deaths will bring up headlines proclaiming that Kimberly ‘killed’ the patient, or made a ‘blunder’. Words are important and this type os sensationalized creates an impression she was intentional, even when the word accidental is inserted, or careless when she blundered. One report tells of the hospital being found blameless yet Kimberly was still under investigation when she took her own life. Yet, how can the hospital be found blameless while the nurse’s investigation was still underway. They are tied together unless the belief is that she intentionally overdosed the child. The hospital fired her following this event, which implies she was at fault, and fault implies that she could have done differently. She was then painted from that moment onwards as the nurse who made a careless blunder and killed a child, was fired from her career and under investigation. Since the hospital was blameless, it must have been her fault, and fault is what our society so dearly looks for.

This fault find, searching for a scapegoat culture in an industry that is so complex, creates a further layer of fear and mistrust where what is needed most is trust.

When I needed to arrange an interview this week between two nurses and the consultant from patient safety department who was doing a review of an event that occurred a week previously in our unit, the first thing the nurse who had been in charge ask was if she needed to bring in someone with her like her union representative. I carefully explained that the interview was not about finding out WHO was at fault, but rather about finding out HOW this happened and how could it be prevented from happening again. In a culture where you can be fired when an error happens you sense distrust that you can come forward and acknowledge and error made.

Another event shone a light on the complexity of the system when the discovery was made that using the Lifescan glucometer in an environment that had been cleaned with a hydrogen peroxide cleaner could result in false high readings. In the investigation into this it was discovered that someone somewhere in the organization had knowledge about this several months ago, but how did the information not get shared? Just exactly who do you talk to when you need to get such information out to such a wide group in a rapid time to prevent potential injury and error? No one seems to know and no one seems to be willing to take the step of making a wide sweeping recommendation about what to do. And so, another week will go by where the information remains held by a few. Communication is so very important but so very few of us do it well.

And deep inside this complex culture an experience nurse complains about trivial things – ‘Who is supposed to clean the mouse?’, ‘Why does the pyxis machine take so long to open?’, ‘the keyboard tray drops down too far!”, all indications of victimhood, deeply held belief that someone else is responsible and the completion of a workplace hazard identification rather than the self-awareness of individual responsibility.

In another place deep inside the complexity another nurse administers a potentially life altering medication. She was interrupted 5 times in the mixing and administering of that medication which was ordered by a physician and verified by the nurse as the correct drug because it was not legible, while the physician was accessing his iphone at the same time as talking to her, and obtained from the pyxis machine that dispensed the medication from the drawer which had been filled 2 hours earlier by a pharmacy technician who was new to the job, and decided upon by the care team based on information provided by the patient that he had only an allergy to some antibiotic, I think it was penicillin.

I wonder how many times I administered a medication that harmed a patient that I never even knew about.

Go safely about your business, there is nothing to see here. Move along.


Do you know how close you are to disaster?


An interesting experience today showed me, once again, just how close we teeter to the edge of disaster in healthcare.

A few months ago medical device notice came across my desk from ERCI telling of problems with the LifeScan glucometer and cleaning with certain hospital products – specifically ones with hydrogen peroxide (H2O2) as an ingredient. So I sent it around, made sure everyone knew not to clean the monitors with the specific products that could alter the readings into false high readings. All was good – we were not using the specific wipes to clean the little hand-held monitors and we went on our business of performing blood glucose measures every 4 hours and making treatment decisions based on the readings.

So today, I hear about a ICU that discovered a reading of high that was, upon confirming with the lab, really normal. In doing some testing with placing their glucometers on surfaces recently cleaned with products containing hydrogen peroxide they discovered that just being in the vicinity of environmental areas that have been cleaned with H2O2 products can alter the glucose read upwardly. Holy crap on a stick.

This started a kuffufle of activity in trying to determine what we could do about this as all the monitors used in the area are the LifeScan monitors and while other company monitors don’t do this, it will take a few days to possibly weeks to make a change over. In the meantime there is a very real possibility of patients being treated erroneously based on a glucometer reading – or not being treated based on a glucometer reading. Chaos was knocking loudly on the door.

In trying to figure out our next steps I started digging – ECRI and FDA yielded nothing about this looming disaster. Google the one true God was there for me though. I discovered technical Bulletins released in April and June that clearly indicted this problem when the monitors were used in an environment that had been cleaned by these products. How was this information not passed along to a wide variety of care providers and locations? I had to dig to find this out and only after I had heard something about it first. How many patients have received or not received treatment based on wrong clinical measurements. Worse, how many have died?

I can feel the panic clawing at my guts when I look to try to figure out how we can suddenly accommodate hundreds of glucose measurements that need now to be performed in a different way. There is not the manpower to do it. The ensuing confusion and chaos will ultimately mean someone somewhere will have their blood glucose measurement done wrong and a wrong reading will be used to assign treatment and things will go badly.

Once you know about a problem you have to act. To know about it and wait is to put patients in danger and to be culpable in any harm.

Discussions and potential plans ensued while I continued on the track of cleaning solutions rather than changing glucometers and method of obtaining glucose results. Could we change the product?

Delight and relief to discover our site has not been using H2O2 products! We are free and clear, however, not so other places. In searching out this mystery I discover that the H2O2 products can take varying amounts of time to clear from affecting results (48 hours to 6 days!)

And so I reflect, as we are told we should do in these times, on how very closely we stand to the edge of danger. How easily a previously unknown chemical reaction can alter your treatment selection, and once implemented, harm a patient. How the hell do you deal with this kind of knowledge of the precariousness of health care? What’s more, how can we be assured of current up-to-date information on such discoveries that impact on our patient care? In doing some further digging I find that both providers and researchers at Calgary and Montreal discovered information about the artifical high glucose reading when the glucometer had been cleaned with Virox in 2005. 2005! Six years later we finally hear of it and then shortly afterwards the danger of using the H2O2 cleaning solutions in the environment where the monitors will be used.

Is it just me who sees a problem here?

Do not go gentle into that good night

There I was, slogging my way home, grumbling in my head about how tired I was, what a long way it was, how I wished there was a place to rest, blah,blah,blah. Ahead of me on the next corner I noticed an elderly man standing out in the road looking around. He had a cane and was carrying his jacket and he moved back on to the sidewalk and looked around some more. By that time I was up to where he was.

“Did you get turned around?” I asked him, hoping he lived close by.

Well he knew where he was supposed to be but not where he was. As we stopped and tried to figure out the address of where he lived, the mosquitoes started to swarm us both. He pulled out his wallet and slowly rifled through it looking for something with an address. He wore a name tag which was helpful, but no address was to be found.

Enter the smart phone. The damn thing has been more trouble than it is worth since I got it, but here, swarmed by nasty biting insects with an elderly man who needed to find his way home, it suddenly leaped into usefulness. Browser actually worked, thank the google gods, to find his residence and a phone number.

I called. I have a client of yours’ off a few blocks from home can you send someone out to meet us? Well no, they couldn’t. The manager was not there and there was only two staff in the residence. Two. How many residents do you think live in that 4 story senior’s residence?

We are walking back towards the residence I told them, you need to send someone out to meet us as we walk there.

And so, along the way we meet one of the staff. Likely from the kitchen by the looks of her uniform. He doesn’t recognize her but she recognizes him. They didn’t know where he had gone because he hadn’t signed out. How long was he gone? No clue, but the whole incident gave me the shivers.

The elderly get placed in a facility that supposedly provides care of varying levels for them. Yet most often they just need someone to watch out for them, to help them remain independent and active. Smart of him to get out and go for a walk, but when the houses all look the same and it is easy to get turned around, you just need a little help along the way.

So back he goes to the facility, where I wonder what level of care he is provided. Will they restrict him because they have no staff, from his walks to Whyte Ave? Will they recommend he get placed in a more secure environment? Will he now lose more independence and abilities?

I worry for our elderly.