ReThinking Patient Safety

Sebelius Urges IHI Attendees to ’Work Harder’ Toward Quality

Sebelius Urges IHI Attendees to ’Work Harder’ Toward Quality.

Housekeeping - updating research links

As a courtesy to my readers, I have updated some of the pages of links that I use regularly. You can access them on the right side of the page. Here are a few pages that have just been updated. I hope to keep expanding the list. How can I make www.ReThinkingPatientSafety.com   helpful to you?  Post a comment below or e mail me at    rethinkingpatientsafety@gmail.com.

 

Medical Search Engines:

http://tinyurl.com/Medical-Search-Engines

Medical Research Links:

http://tinyurl.com/Medical-Links

General Internet Utilities: 

http://3.ly/LeeTilsonInternetUtilities

Texas Nurses - Dr Rolando Arafiles links: 

http://3.ly/ReThinkingPatientSafetyLinks

Texas Nurses - Dr. Rolando Arafiles statutes and government links: 

 http://3.ly/ReThinkingPatientSafetyTexasNursesStatutes  

 

Let me hear from you. rethinkingpatientsafety@gmail.com.

Is Dr. Kevin Pho (www.kevinmd.com of MedPageToday) Right? Does the Malpractice System Improve Patient Safety?

(Link here: http://3.ly/LeeTilsonVsDrKevinReTortReform)

 

Two days ago,  www.KevinMD.com asserted in its headline that:

Dr. Kevin: "The malpractice system doesn’t improve patient safety"

The blog piece begins discussing a case of "wrong hand" surgery cited in a recent journal article. The circumstances involved were disclosed promptly to the patient. Dr. Kevin applauds the physician for the prompt disclosure and describes it as "long overdue." *(See footnote below.)

 

Dr. Kevin refers without citation to articles showing that apologies lead to lower rates of being sued. He quotes a New England Journal of Medicine Article by Hilary Clinton and Barack Obama that most medical errors were due to system-wide causes and not bad doctors.  Dr. Kevin next  asserts that the malpractice system does a lousy job of improving patient safety or compensating injured patients.  He claims that adversarial nature of the malpractice system prevents the apologies that would lead to progress. 

 

The evidence cited does not support Dr. Kevin's conclusion. 

 

Purpose of the tort system: Create incentives to avoid injuries 

The tort system, by itself, will not prevent injuries. The tort system provides incentives to prevent injuries. Juries and judges are not in the business of making specific recommendations to courts as to how to prevent malpractice in the future. That is outside of the expertise of the judges and juries. If the healthcare industry and healthcare professionals choose to ignore the lessons of the malpractice system, whose fault is that?

 

What role do the courts play in preventing injuries? The courts create incentives to be careful and pay attention. Isn't that what courts should do? Can they do more? Should they do more?

 

When Drivers Ignore Red Lights, Do We Abolish Traffic Courts?

Consider traffic signals. If a driver ignores a red light and drives through an intersection, is that the light's fault? What changes should be made? Do we get rid of traffic signals?  Do we abolish the rights of injured pedestrians to sue negligent drivers? Do we say that the cause of the injuries is the court system? Who would accept the argument that the court system causes the injuries by preventing negligent drivers from openly discussing why they ran the red lights?

 

More important, does that fact that a number of drivers choose to ignore traffic lights thereby injuring people mean that the court system is not working? Hardly.

 

Our courts are not the only institution in society. Our courts are a backstop. That backstop comes into play when all the other mechanisms for preventing injuries fail. The courts are a way to tell the other institutions that a problem exists. That message is being sent, loudly and clearly.  Some refuse to hear the message and suggest executing the messenger.

 

Has anyone listened to the messages of the courts? What happens when the message is heard? We get the most effective methods of ensuring patient safety to date: closed claims studies.

 

Lessons of the Tort System: Closed Claims Studies 

 

The real question is not whether the tort system solves the problem of medical malpractice, but whether it can be a part of a solution.

Are we better off with the tort system than we are without the tort system? 

The Anesthesia Closed Claims Project resolved that issue decisively and positively. Article after article on recent patient safety efforts show a disappointing lack of progress with one exception: closed claims projects. The stunning success of the Anesthesia Closed Claims Project shows the path for patient safety. The starting point is an analysis of malpractice claims.

Following the advice of Dr. Kevin and other tort reformers would take away the starting point for the one and only method that seems to improve patient safety. 

 

Links:

articles:   http://3.ly/TilsonsSelectAnesthesiaClosedClaimsCases 

and

free articles:        http://3.ly/LeeTilsonAnesthClosedClaimsFree

 

What do you think?  

Click on this link to access page for comments. 

 

*Footnote:

While Dr. Kevin's article applauds the disclosure of a "wrong hand" surgery, does that really matter? (Note: some disagree with Dr. Kevin's description of that case.)  Put yourself in the position of the patient that had undergone surgery on the wrong hand. Whether disclosed or not, this patient would have know that an error had occurred. Even a mere patient likely knows one hand from another, and which hand needed surgery. Was the disclosure the result of altruism or necessity? While no ad hominem against the surgeon is intended, this is one of the few cases where the patient would have known of the error even absent disclosure. 

Texas Hearing for Dr. Rolando Arafiles

Those who hope nurses can help straighten out the epidemic of poor medical care need to watch this case. 

Texas Medical Board  vs  Dr. Rolando Arafiles

Case # 503-10-4941.MD                    

(At the time this post was written, the mediation hearing was announced at this url:  http://www.soah.state.tx.us/Docket/SOAH.pdf. Updated daily, the announcement is no longer listed on this page. The url is included so that the reader can watch for future announcements.)

The hearing is scheduled for Dr. Rolando Arafiles,  the Texas doctor who engineered criminal prosecutions of two nurses for reporting him to the Texas Medical Board.  Prosecutions of nurses for reporting physicians to a state medical board for improper patient care appears to be unprecedented. According to the docket sheet and information from the Texas State Office of Administrative Hearings, the matter is scheduled for mediation on December 2, 2010, at 9 AM. 

Docket  

http://www.soah.state.tx.us/Docket/SOAH.pdf  (See above re: updates to posts at this url.)

For more information on the SOAH including contact information for that agency, see 

http://www.soah.state.tx.us/Docket/general.asp

 

The charges against Dr. Rolando Arafiles include the improper medical care that led the two Winkler County nurses to report Dr. Arafiles to the Texas Medical Board. The complaint also charges Arafiles with subsequent witness intimidation arising out of his conduct after those reports were filed. After the Texas Medical Board was notified of the improper medical care,  Dr. Arafiles persuaded the Sheriff to investigate the reports to the Texas Medical Board. As a result of the Sheriff's investigation, two nurses, Anne Mitchell and Vicki Galle, were charged with ten year felonies for misusing medical information, and their employment at Winkler County Memorial Hospital was terminated. Charges against Galle were dropped shortly before trial. Nurse Mitchell was acquitted. According to conversations with friends in Texas, the nurses remain unemployed. 

 

These prosecutions garnered national attention. One prominent publication included this incident in the top ten stories about healthcare for the year. 

 

This blog has covered the prosecution of the nurses at length in these prior pieces: 1 2 3 4 .

 

This week, keep your eyes on Texas. Here is your guide to keeping informed.

Formal Complaint against Dr. Arafiles

http://reg.tmb.state.tx.us/TMBPublicWebSite/WEBDOCS/e00/00/99/000099A5.pdf and

 http://www.casewatch.org/board/med/arafiles/complaint_2010.shtml.

Notice of Hearing

http://reg.tmb.state.tx.us/TMBPublicWebSite/WEBDOCS/e00/00/99/000099A5.pdf

Arafiles Testimony from the trial of Nurse Anne Mitchell

http://www.texasnurses.org/associations/8080/files/TranscriptRolandoArailesTestimony.pdf

Mission of Texas Medical Board   

http://www.tmb.state.tx.us/boards/mbmis.php

Mandate of Texas Medical Board  

  

http://www.tmb.state.tx.us/boards/mbman.php

Contact information for Texas Medical Board

http://www.tmb.state.tx.us/agency/contact.php

Sitemap of Texas Medical Board website   

http://www.tmb.state.tx.us/sitemap.php

E mail addresses of Texas Medical Board Staff  

http://www.texasmedicalboardwatch.com/id39.html

Texas Medical Board Information

http://www.tmb.state.tx.us/boards/medbd.php

Members of the Texas Medical Board     

http://www.tmb.state.tx.us/boards/Medical-Board-public-list-12-09.pdf

Prior Blogs on Winkler County Nurses:

http://tinyurl.com/Texas-Nurse-Silence-Kills-1

http://tinyurl.com/texas-nurses-not-too-late

http://tinyurl.com/Texas-Nurses-Links

http://www.rethinkingpatientsafety.com/my-blog/we-are-proud-to-stand-with-anne-mitchell-and-vicki-galle.html

 

The Purpose of Malpractice Litigation - - - a starting point, not a complete solution

BMJ Reports on Risky Business Conference

Debate on Malpractice Litigation

The British Medical Journal reported today on a debate over the benefits of malpractice litigation at the Risky Business conference in London earlier this month.  Glasgow University Professor Shelia McLean argued that litigation creates secrecy and defensiveness, and preventes the open discussion necessary to learn from mistakes. Available to only a few who can afford lawyers, litigation precludes the collaboration necessary to prevent future mistakes.  (See http://www.bmj.com/content/341/bmj.c6703 or http://www.ncbi.nlm.nih.gov/sites/pubmed/21106631.)   Barrister James Badenoch contended that fear of litigation was the “principal driver of risk management and risk avoidance.” The cost of the proposed alternative no fault system is prohibitive.

 

Does Debate Miss the Point?

Whether these two positions are inconsistent seems to depend on whether litigation alone is supposed to eliminate bad medical care. Probably, both Badenoch and McLean would agree that litigation system provides an incentive to eliminate poor care. Probably, both would agree that:

• litigation has not yet accomplished that goal, and
• litigation alone is insufficient to solve the problem.  

This apparent disagreement over whether "litigation is a good method for dealing with medical malpractice" masks the real issue:

• How can we prevent patients from being harmed by medical malpractice? 

Additional Considerations

1. While "litigation alone" as a strategy has not solved the problem, alternate strategies without litigation have also failed. Studies have documented the failure of the available alternative approaches put forward by the patient safety movement. (See http://www.rethinkingpatientsafety.com/my-blog/2010/11/is-iatrogenic-injury-inevitable.html.)
2. We should not lightly toss aside a Constitutional right without a compelling reason. Those who want us to abandon our Sixth Amendment rights ought to show, at a minimum, that the benefits outweigh the cost. Where is the benefit to sacrificing this right? There is no basis for believing that sacrificing a constitutional right is likely to make patient care safer. In fact, the opposite is true. The most successful safety effort began with closed claims. 
3. Litigation was the first essential component of the most effective patient safety effort to date: the anesthesia closed claims project. That project began by examining closed medical malpractice claims. It devised strategies for preventing the harm to the patients. Without litigation, the most effective patient safety effort to date would not exist. There would be no starting point. 

Eliminating litigation would seem unwise for at least three reasons. 

The failure of litigation alone to solve the malpractice problem does not mean that litigation is not a part of a solution.

 The only successful attempt to solve the malpractice problem has been based on data from litigation.

Eliminating litigation infringes on a constitutional right. 

Medical Malpractice System: Provides Incentive and Starting Point

Medical malpractice litigation serves two purposes: it provides an incentive to fix the medical system, and the data that serves as the starting point for making repairs. Alone, medical malpractice litigation cannot fix problems in the healthcare system that the healthcare system does not want to acknowledge or fix. 

What do you think? Let us hear from you. 

Lee Tilson   rethinkingpatientsafety@gmail.com

Risky Business Conference Links

• http://www.risky-business.com/themes
• http://www.risky-business.com/events-live?date=2010-11-18
• November 17, 2010,  http://assets.videojuicer.net/riskybusiness/5e390344-edb1-11df-a78d-1231390c28d1.pdf
• November 18 & 19, 2010,  http://assets.videojuicer.net/riskybusiness/5e2fd29c-edb1-11df-af32-1231390c4211.pdf

 

What do you think?

Is Iatrogenic Injury Inevitable?

No Progress

Sadly, yet another study shows that many patients are harmed by their medical care, iatrogenic injury. Worse, significant effort over the past decade by leading minds in medicine, state and federal governments,  professional medical associations and thousands of advocates have produced little impact. The most recent study indicates that the rate of patient harm produced by medical error remains relatively constant. (See http://www.nejm.org/doi/full/10.1056/NEJMsa1004404#t=article. The abstract appears at http://www.ncbi.nlm.nih.gov/pubmed/21105794.)

The Study: Respected Researchers Review 588 Cases

Despite some criticism of the methodology, the study cannot be lightly dismissed. The authors reviewed 588 cases randomly selected from 10 hospitals in North Carolina, a state generally respected in the medical community for its attempts to promote safe patient care. The authors are well published and respected. A search of Pubmed identifies over 350 articles by these authors dating back to 1973 (http://tinyurl.com/356-articles-by-Landrigan-etc) 39 of which are review articles (http://tinyurl.com/39-reviews-by-Landrigan-etc). (Note: they have published 11 articles in both JAMA and the New England Journal of Medicine. ) Landrigan and his co-authors hold prominent positions in medicine. 

• Landrigan: http://sleep.med.harvard.edu/people/faculty/226/Christopher+Paul+Landrigan+MD+MPH
• Parry: http://connects.catalyst.harvard.edu/profiles/profile/person/51398   
• Sharek:  http://fsi.stanford.edu/people/pauljsharek
• Goldmann:  http://www.ihi.org/ihi/aboutus/people.aspx#DonGoldmann

Conclusion Consistent with Prior Studies

These findings are consistent with what other studies have been showing in the past decade:

          little if any measurable progress. 

• 2005 Leape & Berwick in JAMA  -  http://www.ncbi.nlm.nih.gov/pubmed/15900009

 

• 2006  Stelfox, Palmisani, Scurlock, Orav, & Bates in Qual Saf Health Care. - http://www.ncbi.nlm.nih.gov/pubmed/16751466 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464859/pdf/174.pdf

 

• 2006 Pronovost, Miller, & Wachter  in JAMA -  http://www.ncbi.nlm.nih.gov/pubmed/16896113

 

• 2009 McGiffert, McCauley, & Levin  Consumers Union Report: "To Err is Human, To Delay is Deadly" - http://www.consumersunion.org/pub/core_health_care/011324.html - http://www.safepatientproject.org/safepatientproject.org/pdf/safepatientproject.org-ToDelayIsDeadly.pdf

 

• 2010 Wachter in Health Affairs  - http://www.ncbi.nlm.nih.gov/pubmed/19952010

It is time to re-think the approach being taken to patient safety. The approach we are using has not worked, is not working, and cannot reasonably be expected to work in the future. 

In the coming weeks, lessons from successful attempts to reduce injuries will be discussed. 

_______

Government Citations

• Women's Health  http://womenshealth.gov/news/english/646530.htm
• Minority Health   http://minorityhealth.hhs.gov/templates/news.aspx?ID=646530
• Healthfinder  http://healthfinder.gov/news/newsstory.aspx?docID=646530
• Medline Plus  http://www.nlm.nih.gov/medlineplus/news/fullstory_105958.html

News References

• The Examiner  http://www.examiner.com/children-s-health-in-providence/medical-errors-and-patient-safety-protecting-your-family
• Google News  http://news.google.com/news/story?pz=1&cf=all&ned=us&hl=en&ncl=dxCT0QHL_FmRUfMYPGFr94AfApH1M
• More Google News  http://news.google.com/news/more?pz=1&cf=all&as_qdr=w&as_drrb=q&cf=all&ncl=dxCT0QHL_FmRUfMYPGFr94AfApH1M
• Globe and Mail  http://www.theglobeandmail.com/life/health/paul-taylor/safety-measures-havent-reduced-hospital-errors-study-shows/article1813618/
• Reuters  http://uk.reuters.com/article/idUKTRE6AO0C220101125
• Business Week  http://www.businessweek.com/lifestyle/content/healthday/646530.html
• Web MD  http://www.webmd.com/news/20101124/study-no-improvement-in-hospital-safety
• Bloomberg  http://www.bloomberg.com/news/2010-11-24/medical-injuries-harm-18-of-hospital-patients-in-n-c-researchers-find.html
• MSNBC  http://www.msnbc.msn.com/id/40361672/ns/health/
• Boston Globe  http://www.boston.com/news/health/blog/2010/11/_soon_after_the.html
• New York Times  http://www.nytimes.com/2010/11/25/health/research/25patient.html?_r=1&partner=rss&emc=rss
• UPI  http://www.upi.com/Health_News/2010/11/26/Despite-efforts-medical-errors-persist/UPI-53461290815556/
• Medical News  http://www.news-medical.net/news/20101125/Hospital-errors-in-US-continue-despite-efforts-Study.aspx
• Med City News  http://www.medcitynews.com/2010/11/1-in-5-hospital-patients-injured-during-care-morning-read/
• Mother Jones  http://motherjones.com/kevin-drum/2010/11/hospitals-still-bad-your-health
• Doctors Lounge  http://www.doctorslounge.com/index.php/news/pb/15913
• All Headline News  http://www.allheadlinenews.com/articles/7020634517?Medical%20Mistakes%20Still%20Common%20In%20U.S.%20Hospitals
• Physorg  http://www.physorg.com/news/2010-11-hospitals-reduction-adverse-medical-events.html

 

Is it fair to finalize opinions before oral argument?

Having "notice" and an "opportunity to be heard" are central to our American concept of justice. Accordingly, I was disappointed to read a recent blog piece by David Schock on the Michigan Supreme Court at Delayed Justice . The blog produces images of what appear to be internal memos showing some of the Michigan Supreme Court justices drafting the court's opinion on April 7, 2003, in advance of the April 9, 2003, oral argument. 

Here is a link to the opinion. 

In Re JK, Minor. FAMILY INDEPENDENCE AGENCY, Petitioner-Appellee, v MELISSA KUCHARSKI, Respondent-Appellant

According to Lexis, the hearing occurred on April 9, 2003. That hearing date is confirmed here.

Mr. Schock's posts images of memos dated April 7, 2003, posted on his Delayed Justice website. 

Delayed Justice

 

I am unable to verify independently that the memos were sent. Accordingly, copies of those images are not posted here. See Delayed Justice. 

 

What do you think?  Should the language and footnotes of the decision be finalized prior to oral argument? 

 

Is this fair? 

 

 

 

Medical Research

 Complexities of medical research can overwhelm those in medical crisis.  The mother of invention, necessity has a nasty habit of forcing us to navigate those complexities when we have the fewest resources. Newbies to medical research may find the following  of assistance. I welcome your suggestions. 

ADJUSTING YOUR PERSPECTIVE TO LEARN A NEW FIELD

A. People are not widgets. Two people can have the same medical problem with different findings. Similar symptoms can be produced by differing causes.

B. Do not rely on one source of information whether it is one doctor, one article, one textbook, one website, or one journal. Initial searches of the medical journals that identify fewer than a hundred articles on a subject are probably missing the motherlode of information. Look for synonyms for the key search terms. 

C. An overview is invaluable. Read a variety of articles presenting a variety of perspectives. Read about the controversies and current research. 

D. Don't re-invent the wheel. Talk to others who have faced the same challenge. Patient support groups are invaluable. 

The following links can be invaluable, especially for the non-professionals.

1. Medline Plus summaries (one of many types of information available at http://www.medlineplus.gov )  of the disease under investigation offer collections of links to the best sources of information available including patient advocacy groups, professional organizations, established guidelines, government agencies, and leading medical literature. Searching this website identifies a multitude of reliable sources of information. An actual "Medline Plus" summary offers the most links to the most reliable information available. 

2. The scope of information available for the uninitiated through the following government website hubs is outstanding:  http://www.medlineplus.gov, 

http://www.healthfinder.gov/, and http://www.nih.gov,

3. Pubmed - http://www.pubmed.gov - the access tool for the National Library of Medicine's entry to articles appearing in thousands of medical journals. To develop an overview, one can retrieve the last 200 to 500 articles published on a subject, display 100 or more abstracts, and scan them. Before you can digest the information, you have to develop an overview. Scanning several hundred abstracts over a half hour or two assists in providing the overview necessary to begin understanding the complexities of the literature. 

Articles designated as "review" articles, especially if they are recent review articles written at the invitation of a major journal for the purpose of "reviewing" the literature in the field are often worth extra attention. 

Cochrane reviews offer fairly comprehensive reviews and updates of the literature.

 

4. Clusty - http://www.clusty.com - Vivisimo's ingenious search engine that "clusters" results has become a fixture at government websites for a good reason. Scanning results of a Clusty search almost always provides a reasonable overview of the organizations and major directions relating to a subject. Unlike Pubmed, the results are not limited to medical articles, but include professional organizations, government organizations, patient advocacy groups, news, funding sources, and more. Every use of Clusty generates a new "dummies guide" for what is available on the internet for the search terms entered. 

5. National Academies Press -  http://www.nap.edu - publishes a number of books issued by the Institute of Medicine. Many are available online without charge. Almost all can be read online free. While many topics are not covered, the treatises available tend to be balanced, fair, comprehensive, and well written. 

More to follow. 

 

The Nurses Have Been Standing Up For Us All Along: Rethinking the Role of Nurses in Patient Safety

Link to this page: http://tinyurl.com/nurses-standing-up-for-us

Comment on this page: http://tinyurl.com/nurses-standing-up-comment

Several events from the last year have changed how we think about patient safety. We are beginning to appreciate the central role of nurses in our health care system. How do we think about the role of nurses?

Our language underscores our recognition of the central role of nurses in the healthcare system. Consider how we talk about vulnerable or sick patients. When we are sickest, we are "nursed" back to health. The highest level of care is one-on-one "nursing" care. Fragile newborns are cared for in the "nursery." Elderly can receive care in "nursing" homes, not "doctoring" homes or "hospital" homes. Despite the critical role of nurses, events of the last year suggest that nurses remain unappreciated. 

February witnessed the Texas criminal trial arising out of two nurses, Anne Mitchell and Vicki Galle, having reported atrocious "medical" practices to the Texas Board of Medicine. http://tinyurl.com/NY-Times-on-Texas-Nurses This outrageous prosecution should have led to everyone who claims to support patient safety to stand up for these nurses. Curiously, the only professional societies who stood with these two Texas nurses were nursing societies. Despite the fact that the past AMA president was from Texas, the organization was curiously silent. Likewise, I could find no statements of support from any professional societies of physicians or hospital administrators. The deafening silence of the rest of organized medicine, except for the nurses' organizations, raises questions about whether the talk about patient safety is simply lip service. (Note: Please feel free to use the "comment" section below to share any support that Anne Mitchell and Vicki Galle received from physician or hospital organizations.)

A simmering dispute between the Temple University Hospital administration and nurses' union came to a boil in March and April.http://tinyurl.com/Temple-Gag-Order-on-Nurses-Un One of the central issues in the dispute was the administration's insistence on a "gag clause." As Mary Ellen Mannix explains: 

According to the union leadership their main concern with the proposed contract is the disparagement clause that has been introduced. It state, in effect, "The Association, its officers, agents, representatives and members shall not publicly criticize, ridicule or make any statement which disparages Temple, or any of its affiliates or any of their respective management officers or medical staff members."

(See Examiner Blog by Mary Ellen Mannix,   http://templewatch.org/,  Temple Watch on Facebook, Philly Fox News. )

In Minnesota and California, nurses have begun taking stands on high patient to nurse ratios that threaten patient safety. According to Med City News, the president and CEO of Minnesota's HealthPartners, Mary Brainerd, rejects the demand of the nurses for staffing ratios. The union for the nurses is seeking to establish staffing levels that are safe for patients. Minnesota Nurse's Association. California nurses point to recent studies showing that staffing levels are associated with lower rates of patient deaths. 

Implications of the California Nurse Staffing Mandate for Other States.  Also see Sacramento Bee: California Nurse-Staffing Law Saves Lives, Study Says. San Francisco Chronicle: Pioneering Law on Nurses Found to Save LIves, Philadelphia Inquirer: More Nurses, Less Death. 

The loudest voices for safe nurse-to-patient ratios comes from the ranks of the nurses. Their message:nurses are willing to strike for safer staffing levels. These are the same voices that inspired the phrases we use to describe the places and methods of care for the weak and the ill: "nursing homes," "newborn nurseries," and "nursing back to health."  

When physicians and hospital administrators in Kermit, Texas, looked the other way on the dubious practices of Dr. Rolando Arafiles, it was two brave nurses who faced criminal prosecution for standing up. In Philadelphia, Minneapolis and California, the nurses are the ones willing to risk their jobs and strike for safer care. 

Earlier this year, this blog asked all of us to "stand up for the Texas nurses. " http://tinyurl.com/stand-with-the-texas-nurses To quote another Texan, this request may have "misunderestimated" the importance of nurses. As this year has progressed, we have seen that nurses are the ones willing to risk what they have for our safety. These are the same nurses who enjoy less pay and prestige than physicians and hospital administrators. The nurses regularly staff the evening and midnight shifts, make sure we receive our medications, and clean up our bodily fluids. Was it the devotion of the nurses to our well being that attracted them to this profession? Was their experience of seeing how their care made a difference in our health what empowered them to risk their jobs for our safety? The answers to these questions can and will be disputed. 

More important are the answers to some other questions. When it came time to expose Dr. Rolando Arafiles' misconduct, where were the physicians and hospital administrators? When it came time to protect the right of the Temple nurses to speak out against unsafe practices, where were the advocates for speaking out for patient safety? Even after studies show that ratios of nurses to patients affect the rate of patient death, only the nurses seem willing to take a stand for better ratios. Much remains to be accomplished on the patient safety front. 

Nevertheless, one conclusion remains indisputable: it is the nurses who have been standing up for us all along. 

The Nurses Have Been Standing Up For Us All Along: Rethinking the Role of Nurses in Patient Safety

Link to this page: http://tinyurl.com/nurses-standing-up-for-us

Comment on this page: http://tinyurl.com/nurses-standing-up-comment

Several events from the last year have changed how we think about patient safety. We are beginning to appreciate the central role of nurses in our health care system. How do we think about the role of nurses?

Our language underscores our recognition of the central role of nurses in the healthcare system. Consider how we talk about vulnerable or sick patients. When we are sickest, we are "nursed" back to health. The highest level of care is one-on-one "nursing" care. Fragile newborns are cared for in the "nursery." Elderly can receive care in "nursing" homes, not "doctoring" homes or "hospital" homes. Despite the critical role of nurses, events of the last year suggest that nurses remain unappreciated. 

February witnessed the Texas criminal trial arising out of two nurses, Anne Mitchell and Vicki Galle, having reported atrocious "medical" practices to the Texas Board of Medicine. http://tinyurl.com/NY-Times-on-Texas-Nurses This outrageous prosecution should have led to everyone who claims to support patient safety to stand up for these nurses. Curiously, the only professional societies who stood with these two Texas nurses were nursing societies. Despite the fact that the past AMA president was from Texas, the organization was curiously silent. Likewise, I could find no statements of support from any professional societies of physicians or hospital administrators. The deafening silence of the rest of organized medicine, except for the nurses' organizations, raises questions about whether the talk about patient safety is simply lip service. (Note: Please feel free to use the "comment" section below to share any support that Anne Mitchell and Vicki Galle received from physician or hospital organizations.)

A simmering dispute between the Temple University Hospital administration and nurses' union came to a boil in March and April.http://tinyurl.com/Temple-Gag-Order-on-Nurses-Un One of the central issues in the dispute was the administration's insistence on a "gag clause." As Mary Ellen Mannix explains: 

According to the union leadership their main concern with the proposed contract is the disparagement clause that has been introduced. It state, in effect, "The Association, its officers, agents, representatives and members shall not publicly criticize, ridicule or make any statement which disparages Temple, or any of its affiliates or any of their respective management officers or medical staff members."

(See Examiner Blog by Mary Ellen Mannix,   http://templewatch.org/,  Temple Watch on Facebook, Philly Fox News. )

In Minnesota and California, nurses have begun taking stands on high patient to nurse ratios that threaten patient safety. According to Med City News, the president and CEO of Minnesota's HealthPartners, Mary Brainerd, rejects the demand of the nurses for staffing ratios. The union for the nurses is seeking to establish staffing levels that are safe for patients. Minnesota Nurse's Association. California nurses point to recent studies showing that staffing levels are associated with lower rates of patient deaths. 

Implications of the California Nurse Staffing Mandate for Other States.  Also see Sacramento Bee: California Nurse-Staffing Law Saves Lives, Study Says. San Francisco Chronicle: Pioneering Law on Nurses Found to Save LIves, Philadelphia Inquirer: More Nurses, Less Death. 

The loudest voices for safe nurse-to-patient ratios comes from the ranks of the nurses. Their message:nurses are willing to strike for safer staffing levels. These are the same voices that inspired the phrases we use to describe the places and methods of care for the weak and the ill: "nursing homes," "newborn nurseries," and "nursing back to health."  

When physicians and hospital administrators in Kermit, Texas, looked the other way on the dubious practices of Dr. Rolando Arafiles, it was two brave nurses who faced criminal prosecution for standing up. In Philadelphia, Minneapolis and California, the nurses are the ones willing to risk their jobs and strike for safer care. 

Earlier this year, this blog asked all of us to "stand up for the Texas nurses. " http://tinyurl.com/stand-with-the-texas-nurses To quote another Texan, this request may have "misunderestimated" the importance of nurses. As this year has progressed, we have seen that nurses are the ones willing to risk what they have for our safety. These are the same nurses who enjoy less pay and prestige than physicians and hospital administrators. The nurses regularly staff the evening and midnight shifts, make sure we receive our medications, and clean up our bodily fluids. Was it the devotion of the nurses to our well being that attracted them to this profession? Was their experience of seeing how their care made a difference in our health what empowered them to risk their jobs for our safety? The answers to these questions can and will be disputed. 

More important are the answers to some other questions. When it came time to expose Dr. Rolando Arafiles' misconduct, where were the physicians and hospital administrators? When it came time to protect the right of the Temple nurses to speak out against unsafe practices, where were the advocates for speaking out for patient safety? Even after studies show that ratios of nurses to patients affect the rate of patient death, only the nurses seem willing to take a stand for better ratios. Much remains to be accomplished on the patient safety front. 

Nevertheless, one conclusion remains indisputable: it is the nurses who have been standing up for us all along.