Rogue nurse highlights dilemma over blame vs. root cause
When should you hold individual to blame rather than the system?
It has been 10 years since the Institute of Medicine's report To Err is Human revolutionized patient safety by encouraging a focus on systemic flaws that allow errors to occur, rather than blaming the individual who actually made the mistake. From the start, however, risk managers have struggled with the idea of how to avoid a "culture of blame" without letting people get away with extraordinary negligence or deliberate misbehavior.
That dilemma surfaced again with the recent scandal at Broward General Medical Center in Fort Lauderdale, FL. In October, hospital officials announced that a 59-year-old nurse, Qui Lan, had reused IV bags when administering saline solution to patients who were at Broward undergoing cardiac chemical stress tests, a clear violation of infection control procedures that, according to the hospital's account, Lan committed knowingly. More than 1,800 patients were put at risk of infection.
Officials at the hospital said they learned that Lan was reusing catheter tubing and saline bags on multiple patients when a call came into the hospital's compliance hotline on Sept. 6, 2009. The caller reported seeing the nurse use the same saline bag and a portion of tubing more than once, according to a statement released by Broward General Medical Center CEO James Thaw. The supplies were intended for one-time patient use during the cardiac chemical stress tests, with which Lan had been assisting since 2004.
The hospital's response was aggressive and public. Extensive information was posted on the hospital's web site and updated regularly, with a link on the home page to the special area set up for all information related to the potential exposures.
"We sincerely regret the actions of one employee, who acted on her own, and chose to disregard infection control standards in the delivery of intravenous fluids," Thaw said in a statement to the community. "We are thankful our compliance reporting system worked and that we were able to address this situation as soon as it was reported. We will take all action required to not only remedy the situation, but also to investigate and evaluate all details."
The hospital suspended Lan, who had a valid nursing license and a clean record, on Sept. 8, and she resigned the next day, the hospital reports. Broward General reported her to the Florida Board of Nursing and also requested a criminal investigation from the local police department. Fort Lauderdale Police spokesman Sgt. Frank Sousa issued a statement confirming the investigation and noting that authorities believe Lan has left the country. She grew up in Malaysia, earned her nursing degree in London, and came to the United States for a nursing job in 1976, according to personnel records released by Broward Health, the tax-assisted entity that owns Broward General.
Broward General is offering free testing for HIV/AIDS and hepatitis B and C to the 1,851 patients who underwent stress tests at its facility during the time in which Lan assisted with stress tests. The hospital also took several steps to assess the potential for infections and correct any systemic flaws that may have made it possible for Lan to violate infection control standards.
"We have consulted with expert physicians and a team of epidemiology and infection experts from the Centers for Disease Control and Prevention (CDC), the Florida Department of Health, and the Broward County Health Department," Thaw says. "Broward General Medical Center also informed the Agency for Health Care Administration, which has completed a site visit as part of their investigation."
After its own internal investigation, Broward General instituted the following corrective actions:
Evaluated registered and licensed staff in the stress lab for adherence to infection control and intravenous therapy policies, and compliance was validated.
Initiated opening all intravenous administration sets in the presence of the patient.
Conducted an assessment of all outpatient procedural areas of intravenous therapy for compliance with infection control practices. Compliance was validated.
Re-educated key staff on basic sterile procedures.
The Florida incident illustrates the ongoing need for vigilance and communication regarding patient safety, says David Maxfield, vice president of research at VitalSmarts, a corporate training company in Provo, UT. He is the leading researcher of "Silence Kills" - a study that exposes communication breakdowns in health care that lead to avoidable medical errors. (Editor's note: For more information on that study, see www.silencekills.014com.) Maxfield says incidents such as these are often caused by health care workers' inability and fear to speak up when they see a colleague make a mistake.
According to his study, conducted by VitalSmarts and The American Association of Critical-Care Nurses in Alisa Viejo, CA, 80% of health care professionals regularly witness their co-workers break rules, make mistakes, or demonstrate incompetence. And yet less than one in 10 say anything about it. In addition, nurses are especially timid when the transgressor is a physician or superior.
Maxfield notes that the nurse was caught when someone, most likely a fellow health care worker, reported the problem through a compliance hot line. That is an endorsement of the use of anonymous help lines, he says, but they are not a panacea. Better is a culture that encourages people to speak up immediately when they see something wrong and removes the threat of retribution.
"Secondly, on a strong team, everyone holds everyone accountable. You don't have to be someone's boss to say that's wrong," Maxfield says. "You could be the housekeeper cleaning the room or the person delivering food to the patient, and when you see this, you know it's wrong. You need a culture in which the norm and expectation is that everyone holds everyone accountable."
Maxfield's research suggests that the health care industry is far from that ideal. When asked if they would speak up about a fellow health care worker failing to wash hands, only about 10% of those he studied said they would. While it is not known how long Lan may have reused supplies, the hospital's response indicates there is reason to fear her alleged misbehavior continued for years. That should be a concern for the risk manager, he says.
"It's a good thing that her behavior was finally reported - and it seems the hospital responded in a very proactive way to the information - but I would be concerned about why she could do this for so long. What does that say about the culture in my hospital?" Maxfield says. "She's been a nurse for more than 30 years. It's mind-boggling to think that she might have been doing something like this for so long."
Maxfield says the facts of the Florida case suggest that the violation of infection control procedures was intentional and possibly even malicious, though Lan's motivation is unknown. This sets the incident apart from other situations in which patient safety clearly was threatened inadvertently, through some fault in processes or procedures, and it brings up the longstanding debate over how to hold people accountable in a "no blame" culture.
Cases of seemingly willful misbehavior are vexing, but Maxfield says risk managers must avoid the temptation to write them off as just an aberration, a wild outlier that never could have been anticipated or prevented. While there always will be some individuals who choose to harm others for their own pleasure or gain, in many cases the willful violation is spurred by more esoteric factors such as being overworked, working at too fast a pace, or being frustrated by conditions that make it difficult to follow proper procedures. In such cases, he says, the violation may be conscious and willful, but it still is spurred by a systemic flaw that should be corrected.
"Maybe there was a convenience factor about getting new supplies. Was it convenient or was it difficult to get what you needed?" he asks. "Did it require some level of red tape or human interaction that this person couldn't deal with? Maybe the solution is making getting rid of the old supplies easier and more visible, and getting the new supplies easier and more visible."
That question about the procedures involved should be a major part of the Broward General investigation into the incident, says Susan Stinson, RN, FACHE, vice president of professional services and clinical practice lead at AmerisourceBergen Drug Corp. in Chesterbrook, PA, and an expert on process improvement as it relates to patient safety. Even if the investigation determines that the nurse knowingly and intentionally deviated from proper procedures, the bigger question is still 'Why?'" she says.
"When the clinician has to go through 20 or more steps to complete a task for patient care, and then have four or five other patients that may require a similar task, multiply that times two or three times a shift, and you are talking about hundreds of steps that must be adhered to, without making a mistake," she says. "Blaming the individual doesn't help solve the real problem."
Stinson notes that since To Err is Human revolutionized patient safety philosophy, the health care industry has reached a better understanding of how important it is to put a support system in place that allows health care providers to do the best they can.
"We are seeing much more of a focus on standardization of processes, eliminating waste, and improving the workflow for the individuals on the front line," she says. "There is more attention now to looking at your processes and trying to anticipate what could go wrong. This is work that really never ends. You're always looking for vulnerabilities."
But what happens when a clinician just does something that seems crazy? Avoid relying on the "bad apple" explanation, Maxfield says. It is too convenient to simply say that the guilty employee simply was a bad apple who didn't follow hospital policies and procedures and there's nothing wrong with the system.
"Apples don't go bad on their own. There are forces in the system that allow them to go bad, provide motivation for them to go bad, or they aren't strong enough bulwarks against that happening," he says. "I would like to think that if I went into a hospital and tried to get away with something like this, just being a really bad apple, the system would catch me. Either the staff would speak up and say stop, or the inventory system would red flag the fact that I had X number of patients requiring IV bags and I only used Y number of bags today."
Even when the misbehavior is willful, there still is the very important question of why it is tolerated for any length of time.
"We have to ask what are the social and cultural norms within this group that could have allowed this to happen? Were there other people in her working group who either saw it or suspected it and somehow let it slide?" Maxfield says. "Did they allow that to become some sort of acceptable norm?"
Maxfield encourages risk managers to study the Florida case for clues about how an incident would play out in their own facilities.
"Don't waste this crisis. Ask yourself what would happen if you had a rogue like this in your own hospital," he says. "How far could that rogue go? Could that rogue go on for 33 years, for a year, for a week? What would it take in my organization to catch someone like this?"
Sources
For more information on accountability, contact:
David Maxfield, Vice President of Research, VitalSmarts, Provo, UT. Telephone: (801) 765-9600.
Susan Stinson, RN, FACHE, Vice President of Professional Services and Clinical Practice Lead, AmerisourceBergen Drug Corp., Chesterbrook, PA. Telephone: (610) 727-7499.
It has been 10 years since the Institute of Medicine's report To Err is Human revolutionized patient safety by encouraging a focus on systemic flaws that allow errors to occur, rather than blaming the individual who actually made the mistake. From the start, however, risk managers have struggled with the idea of how to avoid a "culture of blame" without letting people get away with extraordinary negligence or deliberate misbehavior.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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