Reprint: Body Modification in Nurses

Posted on May 16, 2013 by

I wrote this for another blog and am reposting here because of the number of comments I’ve gotten about it. Most of them are along the lines of “I never thought of it that way.” I generally don’t re-post myself, but thought is good, so without further do, this is reprinted in full from the original.

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I had dinner with a friend who is pierced and tattooed and sits in front of computers all day. “I’m surprised,” she said, “that they let you have all that. Don’t they harbor bacteria?”

For those who don’t know, I have currently the (above neck) piercings: nostril, septum, bilateral lobes stretched to 0 gauge, rook, tongue, labret, and forward helix. But at work I tone all that down to the ear piercings, nostril, and lip. Sometimes not even the nostril. And I wear micro gems in both anyway. In my lobes I almost always wear solid plugs that look like normal earrings. I usually leave the tongue bar in for purposes mentioned below, but I’m one of those closed-mouth talkers where it’s not that noticeable and I can leave it out for up to a week with no issues if needed. After that I have to jaaaaam it back in. Anyway.

Before I address the bacteria issue, I should mention that most objections against bod-mods in nurses are that patients will be bothered by it. I know it’s got to be heavily regional and so on, but my experience is solidly the opposite. So many people have piercings and tattoos that it’s accepted by nearly everyone around here. I say “nearly” but have never had anyone have a negative reaction. On the contrary, the number of times people have complimented me on a piercing or tattoo is so high I wouldn’t even know it. And the elderly LOVE them some facial piercings. The argument that they’ll be offended is bunkum and twaddle. “I love your sparkly lip!” I’ve heard dozens of times. “That’s so cute.” I even cared for a 70-year old with 7 piercings in one ear!

And for peds, people borrow me for my tongue. Many a toddler is swayed by “if you stick out your tongue, I’ll stick out mine, and I have a big EARRING in there!” They love that. Curiosity nearly always wins. It’s far better than holding them down and wrestling a tongue blade down their throats while they scream. Instead they laugh. “Shiny!”

Perception aside, let’s talk about…perception. Do body piercings harbor bacteria? No doubt. A cursory search on PubMed revealed no studies. But research DOES show that rings, fingernail polish, and long nails harbor bacteria, yet these things are allowed. So I pose the question: is it an infection issue or a perception issue here? People are used to lobe piercings and giant studded wedding rings and laquered nails, the last two of which are known to harbor bacteria.

Is it just what we’re used to? Because I’m not seing any evidence that body piercing is unhygienic.

Pierced people are incredibly consciencious about hygiene because we don’t want nasty infected piercings. My face is probably cleaner than most people’s because I clean it a lot. And I don’t rub it on patients. Bacteria-infested wedding rings, tolerated in all hospitals, DO touch patients. So do long fingernails (also tolerated). So do bracelets and watches. I shudder to think about what bracelets get dragged through. I mean, literally, I shudder.

But people are USED to bracelets and wedding rings. As for ear piercings, why are lobe piercings OK but not cartilage piercings? I have two holes in each ear. Should the location matter? Why?

If it’s a matter of pure fashion sense, I’m going to call foul. I don’t like big hairsprayed hair, I don’t like bangles, and I think heavy makeup looks trashy. But a coworker can legitimately come to work looking like a New Orleans whore whereas I might be censured for having a sparkle in my lip and one in my nostril, despite my hair being clean and pulled back, my face scrubbed, and my hands clean and nails clean and short.

I think we just need to PONDER this a little bit. I’m not suggesting that big swastikas tattoed on your face are all right, but this issue is only going to get more prevalent.

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It’s National Nurses Week: Does Anyone Care?

Posted on May 8, 2013 by

I missed National Nurses Day, which was Monday, but I’m still in luck because the whole week is National Nurses Week, ending on May 12, which apparently is Florence Nightingale’s birthday. I had to look that up because I thought it was a totally randomly chosen week invented to give lip service to nurses. It is an American thing, although there is International Nurse Day on May 12. In fact, according to the ANA Web site, there are all kinds of nurse days (National Student Nurses Day, National School Nurses Day, and so on). Nurses should be pleased we have any recognition days all, because since 1953 nurses have been trying to have them designated and their attempts were ignored until 1974, when Nixon gave it a go.

But as I said, I really didn’t know about National Nurses Week until I had dinner with a non-nurse friend on Monday who said she almost shared a Facebook post that said “Thank you nurses, for all the disgusting things you do!” She changed her mind because although she appreciates that, she’s more impressed with the smart and technical things that nurses do. I got behind that. Since then I’ve seen about 40,000 of those “someecards” with quips and quotes to celebrate nurses, and my friend is right: most of them make us look like janitors for the human backside. “Nurses are here to save your *ss, not kiss it” (also involving the backside) is another popular one.

The whole thing is starting to irritate me. I don’t mean to be ungrateful, because I suppose it’s a good thing to have a whole week dedicated to my profession. I would just enjoy it more if the week involved a job perk of some kind (a little bonus? a gift card?) or some thoughtful commentary or public education on what nurses actually do so that the appreciation would last longer. Being thanked on Facebook for wiping butts does not really give me that glow of satisfaction.

It’s too late this year, but what if next year nurses really banded together to educate people on all the things we do? I’m thinking letters to the editor, blog posts, and someecards with actual information on them. Perhaps local newspapers would like to feature a nurse each from several specialties. I guarantee you that most people have no clue how much an ICU nurse or an oncology nurse or a wound care nurse or a hospice nurse actually knows and does. And I’m pretty sure that if they did, they would in fact appreciate it.

Seriously: if you aren’t a nurse, does it really make you respect nurses to see a bunch of poop jokes? Or if you weren’t one, would those draw you to the profession?

What I wish Facebook were papered with would be things like photos of a trauma room aftermath. No, it is not funny. However, that is what we do. That is what we live for: actually saving lives. People have no idea what goes on in the actual down-and-dirty saving of a life. I’d like to show them. Maybe next year?

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HIPAA Just Got Tougher

Posted on May 2, 2013 by

On March 26, HIPAA got a big boost, apparently because so many privacy breaches continue to occur. The government isn’t messing around. The financial hit for institutions doubled, from $25,000 to $50,000 per violation. I’m just guessing, but employers might just fire nurses who cost them that much or put them at obvious risk of doing so. That’s a chunk of change.

The same cautions apply: keep your eyes on your own plate. Log off your computer when you aren’t physically in front of it. Use common sense when you talk about patients (we have one doctor whose voice just naturally carries, and “HOW LONG HAVE YOU HAD PENILE DISCHARGE?” is the kind of thing a patient might complain about). Do not look at a patient’s chart unless you can explain why you are looking at it. It should go without saying, but it needs to be said because nurses still do not realize this: they can track chart accesses! They can do it easily. My hospital uses a few FTEs who do nothing but chart access audits—because that’s cheaper than paying the hit when breaches occur.

So, about privacy breaches: there is good news and bad news from a healthcare standpoint. When one is discovered, mitigating factors may prevail. They involve risk and mitigation of risk. If an iPad containing patient charts gets lost at the doctor’s kid’s soccer game but is later found and nothing had been accessed, that’s really low risk and probably not reportable to the patients involved. But if an unsecured e-mail containing patient data is accidentally sent out to a group list, that’s a problem; it cannot be determined who will read the e-mail. High risk. From this it seems that if you err but no one is likely to harmed, you can escape penalties.

Conversely, privacy breaches have to be reported whether or not the institution considers them to be high risk. The institution got to decide before, which was an obvious conflict of interest. Now the government decides how bad the breach was. No more self-governing.

Major changes are in place for patients’ access to and control over their own data, so expect to hear from patients about them. First, patients can now ask for their medical records in electronic format, and institutions have only 30 days to cough it up. It doesn’t matter if half of the record is in a dusty box in the back of a storage room. Second, patients can request that if they pay in full for a service, the provider will not share this information with the patient’s insurance plan. This is a land mine for healthcare workers. If your HIV patient is treated for PCP pneumonia and his insurance company learns about his HIV status because you forgot to prevent it, that’s going to be a problem. How to prevent it? My hospital has yet to tell any of us about the changes, but I’m sure it’ll be an administrative nightmare.

The changes cover other areas as well. HIPAA now extends to business associates (read about this here, for example, and a few other things. The ones in this post are what struck me as most applicable to most nurses.

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Truly Troubling Upcoming Healthcare Changes

Posted on April 24, 2013 by

The title is slightly misleading because these changes aren’t really upcoming as much as they’ve been here and we are largely just starting to feel the pinch. The “truly troubling” part stands, however. It is extremely difficult to grasp all of the changes coming up. Most involve Medicare reimbursement, and there is no one place to go that breaks it down. I just attended a 2-hour CE class about healthcare reform, and I think everyone there—including the presenter—felt as if we had barely scratched the surface.

I don’t know how partisan these issues are. Does anyone doubt that we needed healthcare reform? I don’t know. Perhaps it is better to try something and revise as necessary than to do nothing, which is what we were doing before all of this started. Perhaps when we cross the starting line and go live with some of this stuff, the disaster will be of such mammoth proportions that the revisions will be swift and decisive. Will that depend on who is in the White House? I don’t know. I don’t know very much, and, as it turns out, neither does anyone else who doesn’t do this full-time. People who aren’t involved in healthcare at all (by which I mean consumers or potential consumers) know the least, but when they learn much about it, they realize, “This is seriously going to affect me.”

My initial issue was basing reimbursement on patient satisfaction. This is utterly ridiculous and doomed to failure. Patients cannot dictate medical treatment, but now, they can, or the medical professionals treating them will not be paid. How so? Mrs. White sees a commercial that she should ask her doctor about a new medicine. She looks online and diagnoses herself with…let’s say, galloping dandruff. She immediately goes to her primary care physician and demands diagnostic laboratory and radiologic procedures that nothing in her clinical presentation or history indicate medically, and she ends her introduction to the visit by demanding the medication.

Her physician is doomed no matter what she does.

If she proceeds with responsible medicine, Mrs. White will probably complain and rate the physician poorly. Reimbursement will depend on patient satisfaction, so eventually this physician’s (publicly available) ratings will go down and so will her income.

If she sends Mrs. White for the MRI and laboratory work she’s demanded, the physician will be penalized for unnecessary work-ups.

This rolls downhill. Do I bust my rear to get an antibiotic started under the timeline for the pneumonia protocol, or do I fuss around the patient’s bedside fluffing his pillow and listening to his complaints? I don’t have time for both anymore. Whichever one I choose is going to have financial consequences eventually.

Currently, the issue bothering me the most is that patients have no culpability whatsoever in many of these decisions. The most idiotic change is that readmission for any reason within 30 days will not be reimbursed. If Mrs. Jones breaks her ankle and then comes back for her COPD, the second stay will not be paid for. If Mr. Jones is admitted for CHF exacerbation and, after discharge, follows none of his careful discharge instructions, thus necessitating another admission, it won’t be paid. It makes no difference that Mr. Jones is taking zero responsibility for his health.

I am alarmed, to understate the situation. Hospitals are having to use FTEs on people to comb through charts and ensure the hospital isn’t losing money over minutiae that can cost it millions of collars. Where do the FTEs come from? Clinical staff. Will decreasing nurses at the bedside increase patient satisfaction? No. Will nursing jobs depend on patient satisfaction (“if your score isn’t above 90% for always, you’re fired”)? I bet they surely will. Does anyone see a vicious circle here?

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Do Nurses Get Paid Enough?

Posted on April 17, 2013 by

I am blessed, apparently, in my indifference to how much money I make as long as it’s enough to pay for what I need and a lot of what I want and lets me save what my financial advisor says I should save. A decade of self-employment made income very fluid for me, and I am grateful for the attitude, because many people count pennies and get all ticked off about the $0.05 less per hour they make. From this, readers can get that I feel I make enough money as a nurse. (But the only thing I spend much money on is gadgets. I have an old Toyota and an old house and a lot of jeans I’ve had for 6 or 7 years. Not everyone lives that way or wants to.)

This came up because a patient’s family member recently said to me, “Whatever they pay you, it isn’t enough.” She said this because she saw me running around busier than a one-armed paper hanger and then heard the patient next door invite me to perform a number of imaginative sexual favors after informing me he would knock off anyone’s head who came near him. None of this made much of an impression on me—situation normal. I told this person, “Most of the time, I think I’m paid fairly for what I do. Other times, there is no amount of money that would be fair.” And that’s true, for me. What is a “fair” amount to pay someone sprayed with blood, vomit, and feces during a bad code only to have the patient die in some awful way? I don’t know.

So, do nurses get paid enough? A wide range exists in nursing salaries, depending largely on geographical location and specialty but also allowing for experience. I looked at nursing salaries by state, per capita income for everyone (not just nurses), and a helpful site that breaks down salary by specialty and will calculate for you what you should be making after you input your zip code.

Apparently I should be up in arms, because I’m not making what the sites say I should. I have to note, though, that nursing salaries are not exactly blue collar salaries; certainly, compared with the per capita numbers, we are doing pretty well. Out of sheer interest I checked “The Chronicle of Higher Education” to see how nurses and college professors stack up, and in my state, associate professors at public 4-year universities make salaries similar to those of nurses. I chose professors as a comparison because that is, I think, generally accepted as a respectable career requiring a great deal of education and commitment.

So many variables apply that a true comparison is difficult, but things to consider include the following:

  • You can be a nurse after just 2 years of education and start making $50,000 per year. It doesn’t work like that for everyone, but it’s possible. Or you can go to school for 10 years, have $100,000 in student loans, and then make $50,000 as a college professor. Fair?
  • Benefits make a big difference in considering wages, and these figures provide no way to factor them in.
  • Cost of living completely skews salary comparisons. I could make $90,000 a year in California, but I would have to live in California, where it costs about three times more to live than it does here.

I think most people would rather make more money, and I am certainly no exception. I just wanted to check the numbers a bit to see how much nurses really are paid, and the answer seems to be “not that badly.”

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Thoughts on Nurses vs Physicians

Posted on April 10, 2013 by

I had a patient interaction that has been making think some more about the difference between the professions of nursing and medicine. I think the general public considers nursing “medicine lite” or something that people do who would like to be doctors but lack the intelligence, drive, time, or finances. I disagree with that, but I do want to make a brief digression to talk up the career of nursing by addressing these conceptions.

There are some incredibly smart physicians, and there are some incredibly dumb physicians. Same with nurses. Same with any job and profession I can think of. I’ve met some physicians so clueless I wonder how they manage to complete normal activities like paying bills. I’ve met nurses so smart I wonder why they’re not brain surgeons. And so I’ve decided that a big part of intelligence must involve deliberately choosing what you want to do for your own reasons and finding a way to do it. For many nurses, we have our reasons, and doing what we want to support ourselves is intelligent. What about drive, time, and finances? Those may be legitimate. I became a nurse in my thirties. I wouldn’t have wanted to begin a second career at that point that would have taken so long to achieve competence and independence in, not to mention another set of student loans—but I know people who have started medical school in later life, so I knew it was an option. In some ways, I did consider that nursing would allow me to work in the medical field without those obstacles, and it does.

What I didn’t realize, and what I don’t think the public realizes, is that nursing is truly separate and requires a different skill set and type of intelligence. Yes, we work as a team with physicians. But we have our own cloud of nurse-specific smarts that I think we should be proud of. In nursing school I was taught that physicians diagnose and treat disease and nurses diagnose and treat the patient’s response to (health and) disease. It sounded trite, but the longer I’m a nurse, the more often I think of that. Perhaps the longer I practice, the more rote it becomes to follow medical orders, assess patients physically, and manage my time appropriately, thus freeing me up to focus more on the patient behind all of those things.

Case in point: I had a young patient on an extremely busy night who was from another culture, had a developmental delay, and needed a pelvic exam. The physician treated the disease. He said, “We need to do a pelvic exam to help diagnose what is causing this pain.” And left the room. My patient said, “He’s not examining my pelvic!” And nursing intelligence had to be used. I could have shrugged and charted that the patient refused the exam. She had the right to do so, after all.

Instead, I made time to pull up a chair and talk to her. She had never had a pelvic exam before, so I got a speculum and let her touch it and showed her how it worked. I talked to her about each thing she could expect and explained why these things were necessary, given her symptoms. She decided to allow it, and in that case things would have gone badly for her without the results.

Physicians do not have time to do things like this, and I don’t know whether it’s because of this that they don’t seem to work with patients in this way or not, but they generally don’t. It is situations like this that make me proud and pleased I chose nursing; it was a perfect example of how we work with physicians, but we are a separate profession with different but vital skills.

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How to Work Out When You’re Busy and Broke

Posted on April 3, 2013 by

A recent study found that 55% of nurses in the study were overweight or even obese. We probably all think we won’t be one of those, but about half of us will. It starts in nursing school. I started bad habits there and watched my peers do the same. Why are nurses so fat?

  • Time: it starts in nursing school. You just don’t have time. Will you spend an hour going to the gym or spend an hour with your kids? That’s a no-brainer.
  • Money: gym memberships are expensive. Particularly in nursing school, money is typically tight. There’s always another fee or another widget needed for clinicals.
  • Convenience: when humans are crunched for time, it is our nature to take the path of least resistance, unfortunately usually fast food or vending machines. Home-cooked meals? Ain’t nobody got time for dat.
  • Schedules: if you work 12 hours, you do not feel like working out or even cooking after work. If you work nights, it can be even more challenging to get motivated to get moving outside work.

    Expensive gyms are not the only option on the block, though, and nurses may benefit from the idea of baby steps (any steps, actually). Moving your body for 10 minutes is better than moving your body for 0 minutes. Moving your body for 15 minutes is better. But doing something is better than nothing, and you can move anywhere. The idea that a treadmill and a rack of weights are required for a workout should be discarded. These are all just excuses. Anyone can fit in a 10-minute walk or workout that can be done on a throw rug at home, even between 12-hour shifts.

    Here are some ideas:

  • Get a kettlebell. I know money is an issue, but they’re inexpensive and provide an all-in-one-gadget workout: check out 22 Kick-ass Kettlebell Exercises.
  • Try systems like Sworkit. It works on the Web or your smartphone. Just tell it how much time you have and what you want to do (cardio? yoga? arms? legs?), and it gives you a workout. If you don’t know what a burpee is, Sworkit will help you out with videos.
  • Similarly, http://thesimplegym.com/ has dozens of workouts you can do at home, and believe me, you’ll be worked out. You can’t order the workouts the way you can with Sworkit, but they do send you one per day via e-mail Monday through Friday. They take about 12 to 15 minutes.
  • Use a pedometer all the time. You’ll find yourself parking farther away or even walking to the store from home just to get your daily step total higher. And no, you don’t need to spend money on a Fitbit. Moves for iPhone is free, and the Google Play store has a ton of pedometer apps for Android.
  • Set aside just one day per week to take a community-offered yoga, pilates, or kickboxing class. Many community centers or parks & rec divisions are untapped goldmines of free or cheap fitness.
  • Take the stairs at work. On break. Seriously, use 10 of your 30 minutes to go up and down the stairs. You’re done.

    These are places to start, but the main thing is, one has to start somewhere. “I don’t have time to work out” simply is not the case, and this post proves it. It looks bad for unfit nurses to discuss healthy lifestyles with patients, so I would argue we owe it not only to ourselves, but also to our patients, to give fitness a shot.

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    How Invasive Do Thermometers Need to Be?

    Posted on March 28, 2013 by

    The area in which I work uses standard practices, as it should, with temperature monitoring. It’s a critical care area, and we can’t really afford to miss things like “whoops; that patient slid into septic shock while we weren’t looking” or “oh my, that week-old infant really did have a fever.”

    But to get these super accurate, standard-of-care temperatures, we often have to be extremely invasive. Every child under 3 years old (it’s supposed to be 5, but if the child can comprehend “hold this under your tongue or it goes in your bottom,” he gets a pass) needs a rectal temperature. Adults who are not able to cooperate with oral temperatures or who have conditions such as sepsis or environmental exposure (a fancy way of saying they were left outside and are too cold) need core temperatures, and those options are rectal or bladder temperatures.

    Patients don’t like this.

    The most common scenario is in triage, in which parents refuse the rectal temperature on grounds it will traumatize the child, and they say, “Can’t you use the forehead ones my pediatrician uses?” I say, “It is our policy based on current research that the rectal temperature will let us treat your child the most accurately.” I really hate it, though. The parents act as if I’m deliberately torturing the child. Oddly, the children are far less bitter about the rectal temperature than the little pulse-oximetry sticker on their toes. They’re just not having that.

    I wondered whether anyone had done research that would allow us to change policies, so I did a little literature review. I mostly focused on pediatric patients, but I found some interesting factoids to consider with adults as well.

    • Study 1. “Bias and precision values for the temporal artery, but not the axillary temperature, were within the acceptable range set by experts to use as a noninvasive substitute for core body temperature measurements. If properly used by ED staff, temporal artery thermometers could be used to obtain temperature in pediatric patients younger than 4 years.”[1]

    • Study 2. “The diagnostic accuracy of the temporal artery thermometer in detecting fever in children of all ages is low.”[2]

    • Study 3. “The results of this study do not support the use of temporal artery thermometry for perioperative core temperature monitoring; the temporal artery thermometer does not provide information that is an adequate substitute for core temperature measurement by a bladder thermometer.” (This study also studied ICU patients.)[3]

    • Study 4. [Emphasis mine] “Oral and temporal artery measurements were most accurate and precise. Axillary measurements underestimated pulmonary artery temperature. Ear measurements were least accurate and precise. Intubation affected the accuracy of oral measurements; diaphoresis and airflow across the face may affect temporal artery measurements.”[4]

    In short, studies disagree, so we should keep doing we’re doing, unfortunately.

    1. Reynolds et al. Are temporal artery temperatures accurate enough to replace rectal temperature measurement in pediatric ED patients? J Emerg Nurs. 2012(Nov 8):pii; S0099–1767(12)00329–7.  ↩

    2. Penning et al. Is the temporal artery thermometer a reliable instrument for detecting fever in children? J Clin Nurs 2011;20:1632–9.  ↩

    3. Kimberger et al. Temporal artery versus bladder thermometry during perioperative and intensive care unit monitoring. Anesth Analg 2007;105:1042–7.  ↩

    4. Lawson et al. Accuracy and precision of noninvasive temperature measurement in adult intensive care patients. Am J Crit Care. 2007;16:485–96.  ↩

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    Newsflash: We Shouldn’t Aspirate Before (Some) IM Injections

    Posted on March 20, 2013 by

    I read this recently and said, “what?” I went to nursing school not so long ago, and they taught us that when you give IM injections you should aspirate before the injection. It was almost one of those obvious things that a nurse would never question, but someone did and studied it and now we have evidence-based research that we’re not supposed to aspirate all the time anymore.

    Approximately 1 year ago, some nurses did some research on the matter and published their results in “To aspirate or not: An integrative review of the evidence.” From what I can tell, their review found more that there was no evidence in favor of aspiration, versus there being evidence against it. The authors established these points:

  • Aspiration is not indicated for subcutaneous injections of immunizations, heparin, and insulin
  • Aspiration is not indicated for IM injections of vaccines and immunizations
  • Aspiration may be indicated for IM injections of medications such as penicillin
  • Until a standard can be established, injection techniques must be individualized to the patient to prevent incorrect needle placement

    • But documentation straight from the CDC (download the PDF here) has a bit more oomph behind the “do not aspirate” idea. It states

    “There are only two routinely recommended IM sites for administration of vaccines, the vastus lateralis muscle (anterolateral thigh) and the deltoid muscle (upper arm). Injection at these sites reduces the chance of involving neural or vascular structures. The site depends on the age of the individual and the degree of muscle development. Because there are no large blood vessels in the recommended sites, aspiration before injection of vaccines (i.e., pulling back on the syringe plunger after needle insertion but before injection) is not necessary…. Also, some safety-engineered syringes do not allow for aspiration.”

    This document also cites studies that avoiding aspiration decreases pain, something that any nurse will be happy to hear. I think we all hate that look and scream from pediatric patients and would like to learn any techniques possible to decrease their pain.

    The CDC document seems to base its recommendation against aspiration on vaccine-specific research and administration locations, and the first study also separates out vaccine versus medication administration. In summary, then, evidence-based practice currently would be to avoid aspiration for vaccine administration in the deltoid or vastus lateralis, for sure and for certain.

    For other IM injections, research is still not convincing, and I would like to see a more compelling answer. The CDC document is unclear because it confines itself to vaccine injections, yet the rationale used should logically apply to any IM injection as long as these two sites are used. If there are no large blood vessels involved for vaccines, the same should apply for Phenergan or Dilaudid or Rocephin, but I hesitate to change my practice on the basis of simply extrapolating results.

    For those of us who give non-vaccine IM injections on a regular basis, this is relevant on a daily basis. If I don’t need to be aspirating before giving already-painful Rocephin injections, I would like to know about it. More research is needed on the matter, and it needs to be publicized more.

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    Nurse Kills Patient With Too Much Morphine: A Cautionary Tale

    Posted on March 14, 2013 by

    This headline from Australia caught my eye: “Nurse Tells of Morphine Mistake.” I am always happy to learn how to avoid mistakes by reading about those of others, and I applaud nurses who voluntarily tell about anything they’ve done wrong. So many times we gossip and put down down colleagues found to have made errors when in fact the errors are systems errors which should be investigated openly. I first heard this idea in nursing school from the Institute for Healthcare Improvement, which had a podcast entitled “Caught in an Error” or similar. I can no longer find it, sadly. The podcast opened my mind to the idea of a systematic approach to preventing errors rather than finding someone to “take the hit.” In general, it takes several people dropping the ball for something truly awful to happen.

    In this post it sounds as if the nurse involved has behaved appropriately. She stated factually what had happened and apparently pointed out systems issues that might have prevented the error. I hope things go well for her. We all make mistakes. We do.

    But they do not all turn out well for the nurse. Consider Kimberly Hiatt, who made a medication error that may or may not have killed a baby. Twenty-four years, one error, and this nurse—who, by all reports, was not held responsible by the family—committed suicide. I remember when this happened. My colleagues and I discussed it, because we work in a critical care area, where your chances of making a lethal error increase exponentially because of the heavy-artillery drugs you are giving.

    “I think I’d just quit before I lost my license,” was the general verdict.

    Aside from the obvious fact that this dodges the issue at hand, it solves nothing for the profession. I could also weave into this post the added issues of physicians hanging nurses out to dry to save themselves and vice versa, but that is another topic. I am talking about nurses accepting responsibility both for their own lapses and for contributing to furthering the profession by sharing voluntarily what happened and asking for dialogue regarding how it could have been avoided.

    Without this, we cannot learn from one another. We must each privately make the same error and learn and suffer privately. This is not in the best interests of patient care. Nurses can learn from others’ mistakes and thereby not make them again, but only if the atmosphere of fear and blame is cast aside and one of forgiveness and remediation put in its place.

    Would Kimberly Hiatt still be alive with such an atmosphere? No one can know. My heart hurts for healthcare providers who make errors caused by systemic situations, fatigue, unsafe staffing ratios, the fact they’ve not eaten for 10 hours, and a dozen other factors that can lead to human error. Neither doctors nor nurses are superhuman, and I do not believe the public expects us to be. They do, however, expect us not to lie.

    A nurse caused serious harm to my then-dying father by giving him a medication he refused at my direction, which was battery. I spoke to her Director of Nursing about the error, and she asked me what I was requesting. “Apology for the extreme harm she caused and her stated plan for remediation” were my only requests. The nurse refused both, and I changed my mind. I’ve made a few errors, and I don’t know any nurse who hasn’t. What I could not get past was this nurse’s refusal to admit her error and simply apologize for the harm she’d caused.

    These are weighty issues to consider, but they need to be aired. I always say “if you find a nurse who says she’s never made an error, she’s lying.” Maybe she’s not been caught, or maybe it was error that came to no bad end, but those are luck of the draw. Mistakes will happen, and they will probably increase as staffing ratios worsen. We need to think ahead about how to support our erring colleagues and foster an environment of education rather than repudiation.

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