Posts Tagged ‘nursing malpractice’

Week in Review (April 18 – 22, 2011) The Eye Opener Health and Law Blog

Saturday, April 23rd, 2011

From the Editor:

This past week, our blawgers (guess I’ll use this term now since we are legal bloggers) were busy on their keyboards once again. They covered a number of topics relating to law, medicine, health and patient safety. This week we posted a primer on aortic aneurysms and how they can present as back pain, a blog about “robot” anesthesiology, a disturbing post about how the recent threat of a federal government shutdown was averted but at a cost to those who are in dire need of healthcare, an interesting piece about laughing gas making its way back into the American medical scene for labor and delivery and finally, and a highly read piece on a not-to-often discussed topic but one of potential grave concern – shift switching by nurses and how this might impact patient safety.

Here’s our usual “quick summaries” for you to peruse, click on, read and comment:

Aneurysms – a deadly condition you need to know about!

Our in-house medical specialist, Theresa Neumann, wrote another highly educational and need-to-know piece about a condition that can present as back pain but which has deadly consequences for those who have this condition.

As Theresa’s research made us aware – “1 in every 50 males over the age of 55 have an abdominal aneurysm, this is a more common pathologic diagnosis than some others.  Men also corner the market at an 8-to-1 ratio as compared to women with abdominal aneurysms.”

As is the case with all of Theresa’s writings, we offer through her valuable information from someone who’s “been there” and “done that” in the clinical setting. Don’t miss her post entitled Aneurysms: A Potential Deadly Condition That May Present as Back Pain.

Who’s using remote control and a joy stick to put a breathing tube down your throat?

Mike Sanders brought to our attention a new practice of anesthesiologists – in Canada – that may soon be part of anesthesia management in the United States as well – using robotics to intubate patients. While you can certainly learn about the concept of intubation by reading Mike’s blog, basically, this is placing a small tube down a patient’s airway so that the anesthesiologist can control the airway and provide ventilation to a patient undergoing surgery.

Here’s an except -

Medical News Today is reporting that Dr. Thomas Hemmerling of McGill University and his team have developed a robotic system for intubation that can be operated via remote control.

For more on this fascinating new project by Dr. Hammerling and his team, read Mike’s post entitled Robot Anesthesiologists?

Government Shutdown Avoided – but who will pay the price for the “deals” that were cut?

The newest member of our blogging team, Jason Penn (fast approaching veteran blawger status) did a fascinating piece of the story-behind-the-story of the recent crisis our country faced when the federal government was on the verge of a shutdown. We all know about deals being cut in the back rooms of congress. We all know that the government avoided a shutdown this time around when the senate and house worked out a compromise that resulted in millions of dollars being earmarked for cuts in the budget.

Jason tells us what programs relating to healthcare will suffer as a result of these negotiated cuts. As some wise person once said, “why is it always those who are least represented who bear the burden of budget cuts?” Maybe it’s because they can’t afford lobbyists to protect them like those who need protection the least can.

Read Jason’s eye opening and no-punches-pulled report on just who will be the victims of the deals in his post of this past week Budget Crisis Avoided, But What About the Babies? Can They Live With $504 Million Less in Funding?

Will moms-to-be now be “laughing” their way through labor and delivery?

One of our seasoned blawgers, who every now and then is driven to report on the off-beat issues of law, medicine and healthcare, Jon Stefanuca, stepped up to the plate once again and took a swing at the return of an old-timer to the arsenal of pain relief for mothers-to-be undergoing labor and delivery – laughing gas!

As Jon’s piece in Eye Opener this past week tells us -

It appears that a number of hospitals are now considering making laughing gas available as a pain relief measure for women in labor. A hospital in San Francisco and another in Seattle have been using laughing gas in their labor and delivery units for a while. Hospitals like Dartmouth-Hitchcock Medical Center plan to offer laughing gas to laboring mothers in the immediate future.

For more about this return of laughing gas to our obstetrical units, read Jon’s piece Laughing Gas Making Its Way Back Into the Labor and Delivery Department.

Nursing and Sleep Deprivation: Is it a risk factor for patient safety?

I suspect somewhere along the line you have done “an all-nighter” – whether it was getting ready for a big test, a social event, or for some other reason. Remember how you felt as you made it through that night or the next day? Have you ever done it several nights in the same week? How about doing it a few times one week and then do the same thing the next week and the next…. Well you no doubt get the idea. You’ve been exhausted, right? Well what about nurses, who have to do this for a living?

Nurses have lives too. They have children, home responsibilities and obligations, and some form of social life. What happens when they swap shifts or are asked to do “a double”?

Sarah Keogh was back blogging this past week and wrote a fascinating (and concerning) post entitled Nurses Switching Shifts: Does a Lack of Sleep Put Patients at Risk? We invite you to read Sarah’s piece and share your comments. Are you a nurse who lives this lifestyle? What are your thoughts about nurses being allowed to work multiple shifts or back-to-back shifts in terms of patient safety? Should there be restrictions on nurses’ shifts just as there (finally) are work restrictions on doctors-in-training?

A “Sneak Peak” of the week ahead

As part of our continuing effort to “get the word out there” on issues relating to health, medicine, patient safety and the law, we post from time to time more extensive research pieces called White Papers. Well, the time has arrived for another White Paper to be posted on our website. Marian Hogan has completed her piece on a very important topic – Patient Controlled Analgesia in today’s hospital environment. She examines how some hospitals are now heavily marketing a spa-like environment so you choose them over the competition. Yet lurking in the shadows of these facilities which promote flat screen TV’s, valet parking, in-room safes and the like is a very dangerous practice: placing patients on patient-controlled-analgesia (for pain relief) without vital monitoring devices and patient safety practices. It’s at the “printer” now; we hope to have it online this week.

From our blawgers you can expect reports on a disturbing fight between manufacturers and child safety experts over – blinds! After decades of controversy, you’ll find out where the battle lines are now drawn, who’s winning and who the real losers are in this war. Wonder how healthcare safety is doing since the report To Err is Human was published by the Institute of Medicine over a decade ago? Jason Penn will be providing an updated report card, which you should not miss. Alcohol and surgery – not a good combination! Jon Stefanuca plans on posting a piece that looks deeper in the obvious problems with this potentially deadly combination.

This is just a taste of what’s to come. I better wrap-up now. I’m working on finishing the third installment on Medical Technology and Patient Safety. Oh yeah, if time permits, I might even get to post a piece I’ve been working on this past week – a lawyer’s rant about our modern day love affair with mediation practices and trends.

As always, don’t forget - subscribe to the Eye Opener and tell your friends about us too! …and… don’t forget to join our social networking communities on Facebook and Twitter.

Hope you have a great weekend!

Why do so many patients die when their in-hospital alarms go unheard or unheeded?

Thursday, February 17th, 2011

ICU alarm monitor

Sunday’s edition (February 13, 2011) of the the Boston Globe online (boston.com) tells a chilling story of how many times the alarms used to monitor patients go unheard and unheeded by medical staff leading to death or catastrophic injuries for patients throughout this country. The story, which was a two part series (for the second installment, see For nurses, it’s a constant dash to respond to alarms) by Globe reporter Liz Kowalczyk, narrates numerous incidents in which alarms simply went unnoticed, ignored or unmonitored. Numerous other issues such as lack of education of hospital staff as to how to properly connect the devices, failures to realize the batteries had gone dead, turning the alarms so low in volume they could not be heard, taping over amplification systems to avoid the “annoyance” of the alarms and the like are also chronicled in this series. While it is documented by an analysis of the FDA’s database of adverse events involving medical devices that 216 patients died nationwide between 2005 and mid-2010, it is also certain that this number of alarm-related deaths is probably much higher. The ECRI Institute, which was hired by the Globe to analyze the FDA database, believes that the health care industry under-reports these cases to the FDA.

Some examples of alarm-related deaths

Since links to the Globe’s original articles are provided above, I will not go into the level of detail that is otherwise available through reading the original reports. Here is a sampling of the types of “alarm failures” leading to patient deaths:

  • staff misprogrammed complicated monitors
  • staff had forgotten to turn the monitors on
  • batteries had gone dead leading and failed to function (one instance where a man had a “flat line” for more than two hours that went undetected)
  • defective wires or connections on the monitors
  • malfunction or design flaws in the monitoring devices
  • staff ignored the device warnings because of “alarm fatigure

Alarm Fatigue

According to one computation at Johns Hopkins Hospital in one 15 bed unit as to how often alarms go off during the course of day, it was documented that there were 942 alarms per day – “about 1 critical alarm every 90 seconds.” There is no doubt that the number of alarms and the clinical settings in which they are used have increased over the years. As Ms. Kowalczyk noted, “[W]ith the use of monitors rising, their beeps can become so relentless, and false alarms so numerous, that nurses can become desensitized – sometimes leaving patients to die without anyone rushing to their bedside.”

In some cases, busy nurses have not heard or ignored alarms warning of failing batteries or other problems not considered life-threatening. But even the highest-level crisis alarms, which are typically faster and higher-pitched, can go unheeded. At one undisclosed US hospital last year, manufacturer Philips Healthcare, based in Andover, found that one of its cardiac monitors blared at least 19 dangerous-arrhythmia alarms over nearly two hours but that staff, for unexplained reasons, temporarily silenced them at the central nursing station without “providing therapy warranted for this patient.’’ The patient died, according to Philips’s report to federal officials.

Keep in mind that many of these alarms are not only audible in the patient rooms; they also sound at the central nurse’s station. In some instances, hospitals have put up hallway speakers for nurses to hear the alarms more readily. In other facilities, in addition to audible alarms, various pieces of critical data information (e.g. heart rhythm, heart rate) are visible on displays at nurses stations and in some places, it is reported, “on brightly colored scrolling signs in corridors.”

The article quotes one nurse at Boston Medical Center, who addresses some of the issues at the heart of this “alarm fatigue” phenomenon.

Everyone who walks through the door gets a monitor. We have 17 [types of alarms that can go off at any time. They all have different pitches and different sounds. You hear alarms all the time. It becomes...background

False Alarms - the cry wolf issue

It is well known that some alarms can go off when a patient sits up, coughs, turns or makes other normal movements. According to the Globe report, "'[s]ome studies have found that more than 85 percent of the alarms are false.” I have no idea how this statistic was compiled, but even if it is accurate (which is debatable), that still leaves dozens if not hundreds (if not thousands) of alarms going off daily in every hospital throughout this country that are an indication of a patient in need of rapid response life-saving care.

Another nurse is quoted by the Globe in expressing both the frustration and the need for attentiveness when the alarm goes off. “You have to respond to the alarm[, b]ut there are some days when you feel you’re just running from alarm to alarm. It can be exasperating.”

The Fix

The short answer appears to be: there is no easy, quick fix. Here are some of the measures institutions have taken to address this problem:

  • working with engineers at prestigious institutions (e.g. MIT’s work with Boston’s Children’s Hospital) to develop more sophisticated monitors to identify true crisis alarms.
  • hiring of dedicated monitor technicians and/or nurses, who man the central nurses’ station to triage alarms.
  • specialized education programs to avoid misprogramming or connection mistakes due to lack of knowledge by staff
  • establishing tighter standards of which patients should be connected to alarmed monitors – to cut down on the “background noise” of alarms.
  • replacement of old equipment for more advanced, accurate alarm/monitor systems
  • implementation of new programs in-hospital to require bioengineers to check the monitors daily to make sure they are working properly.
  • implementation of standardized settings on machines so that alarms are not turned so low they are non longer audible. (One case of a patient death was attributed to staff turning the the “vexatious” alarm down to a 40% of full volume – no one responded to an arrhythmia alarm for 40 minutes because no one heard the reduced volume alarm during that time.)
  • changing batteries every day in monitors to make sure they are, in fact, charged and working

The Blame Game

As you might suspect, the finger-pointing that takes place after a patient is found dead or severely injured is rampant. As the Globe reports, “Initially, hospitals almost always blame the monitor’s alarm for not sounding when it should have, according to reports. But the company investigations show the assertion is often false.”

In 40 of the cases reviewed by the Globe, the alarms did not sound, usually because the staff had not properly programmed or turned on the machines.; in only eight cases was there a malfunction or design flaw.

[I]n nearly 100 cases, manufacturers ere unable to determine exactly what went wrong, often because they didn’t have enough information, or they told federal regulators they still were reviewing the death.

Where to from here?

While I certainly don’t have to contend with the incessant noise of alarms going off all day long, nor am I required to jump away from what I’m doing to respond to a false alarm, I can’t help but think that in a health industry as advanced as ours allegedly is, there must be some steps that can readily be taken so that others don’t die because some nurse has “alarm fatigue,” or a battery died, or the volume was turned down too low to avoid the annoyance of the alarm or some other ill-conceived and unacceptable reason.

What suggestions do you have for the healthcare industry to deal with this problem? Have you ever worked in a setting where this is a problem? If so, how did you and/or your institution deal with this issue? There are a lot of smart people in bioengineering and in our health institutions; why is this still such a problem in a country that claims to be so advanced?

Image by ectopicinteractive.com

Expanding The Role Of Nurse Practitioners: Licence To Practice Medicine Without A License

Saturday, February 27th, 2010

An article published by NPR comments on the nationwide movement to expand the role of nurse practitioners in light of the growing deficit of primary care physicians. According to the article:

Nursing leaders say large numbers of [nurse practitioners] …will be needed to fill gaps in primary care left by an increasing shortage of doctors, a problem that would intensify if Congress extends health insurance to millions more Americans. Advocates say nurse practitioners have the extra education and training needed to perform a variety of services, including physical exams, diagnosis and treatment of common ailments and prescribing drugs.

A study published by the Center for Workforce Studies projects that, by 2025, there will be a nationwide shortage of about 124,000 physicians. Researchers note:

Under any set of plausible assumptions, the United States is likely to face a growing shortage of physicians. Due to population growth, aging and other factors, demand will outpace supply through at least 2025. Simply educating and training more physicians will not be enough to address these shortages. Complex changes such as improving efficiency, reconfiguring the way some services are delivered and making better use of our physicians will also be needed.

Based on this rationale, a number nursing organizations, state level legislators, regulatory bodies, and various other national organizations and policy thinktanks advocate for an expanded role, particularly in the field of primary care, for nurse practitioners. According to the article, a number of states have already implemented or are presently considering legislation to expand the role of nurse practitioners. For example, a Colorado bill would enable nurse practitioners to issue orders in the same way as a physician. Practically speaking, this would mean that a nurse practitioner, in addition to being able to order medications, would also be able to issue orders directing the treatment of the patient (e.g., orders to admit the patient, CT/MRI orders, consultation orders, etc.)

While these proposed reforms may be practical and serve a utilitarian purpose, one can’t help but wonder if the quality of health care rendered to millions of Americans is going to be compromised as a consequence. The easy answer is not always the right answer. It may be true that there are more nurse practitioners in the U.S. than there are physicians (there are about 125,000 more nurse practitioners). If allowed, nurse practitioners could certainly fill the void. But, the critical inquiry remains: are nurse practitioners sufficiently qualified to serve as substitutes for physicians? For example,

The American Medical Association (AMA) and doctors’ groups at the state level have been urging state legislators and licensing authorities to move cautiously, arguing that patient care could be compromised.

The AMA issued a report in which it questioned whether nurse practitioners are sufficiently qualified to render medical care in areas currently restricted to physicians.

“To back up its claims, the report cites recent studies that question the prescription methods of some nurse practitioners, as well as a survey that reported only 10 percent of nurse practitioners questioned felt well prepared to practice primary care.”

The idea that nurse practitioners are qualified to serve as substitutes for physicians it truly worrisome. There is a reason why nurse practitioners are not physicians – they don’t have the same level of training and expertise. Surely, there are patients with fairly simple medical complaints, which probably could be addressed by nurse practitioners; however, what about the inevitable complex patient? Are nurse practitioners sufficiently trained to simultaneously recognize the interplay of multiple medical conditions, as well as determine the interplay of necessary medications, radiographic studies and necessary follow up care? I for one will make sure to be seen by a physician.

Contributing author: Jon Stefanuca

Public beware: disciplined nurses crossing state lines to practice anew.

Monday, January 4th, 2010

A recent report posted on ProPublica tells a shocking and scary tale of how some nurses, disciplined in one state, have taken up new jobs as licensed nurses in a different jurisdiction.  This story was brought to light by the combined investigative efforts of Charles Ornstein and Tracy Weber of ProPublica and Maloy Moore of the Los Angeles Times on December 27, 2009.

According to this report, there exists a “dangerous gap” in the way states regulate nurses.  As an example of just how serious a problem this may be, the reporters found that in California alone, a months-long review of the 350,000 registered nurses in that state revealed that there were at least 177 nurses, whose licenses had been revoked, suspended, surrendered or denied elsewhere.

The online article gives the following example (among a number they discovered):

In May 2005, a 3 year old boy, Jexier Otero-Cardona, died while under the care of a home health nurse, Orphia Wilson. The child suffered from chronic respiratory failure and muscular dystrophy.  Early one morning, Nurse Wilson frantically summoned the child’s parents for assistance when the child stopped breathing.  After heroic efforts at CPR by his mother, the child died the  next day at a hospital in Connecticut.

This was not the first child to die under Nurse Wilson’s care, the state’s investigation revealed.  Just seven months before, Nurse Wilson had lost her Florida license due to apparent lapses in the care of another child in that state in 2002.

In the months of investigation by Connecticut officials that followed Jexier’s death, it was determined that Wilson “had fallen asleep, then ignored – or possibly turned-off – the ventilator alarms that were intended to warn when the child was not getting enough oxygen.”

The following quote from the article tells the tragic story of a failed system of regulating the licensure of nursing in our country:

“Florida officials, for instance, didn’t notify Connecticut authorities when they sanctioned Wilson – even though she’d told them that she also held a Connecticut license. And Connecticut’s nursing board renewed Wilson’s license three times after Thierry’s death, relying on her pledge that she hadn’t been disciplined or investigated elsewhere.”

The reporters identify several key failures in our country’s system of regulating the licensing of nurses.  First, they note that in some instances some states do not do a simple check of a national database, which can within seconds reveal (if the data  has been timely and accurately supplied) that a nurse has been disciplined elsewhere.  This has dire implications in many hospitals and health care employers rely on state nursing boards to verify a nurse’s licensure status and fitness to practice.  Secondly, they tell a tale of how long a disciplinary process may take and how long the reporting of that finding will occur, if ever.  The tale of horrors goes on and on.

Just a bit of digging (much more to come!) into the background of this issue reveals that The Medicare and Medicaid Patient and Program Protection Act of 1987 led to the creation of the National Practitioner Data Bank (NPDB), which was a tracking system designed to protect program beneficiaries from ‘unfit’ health care practitioners.  The NPDB was implemented in the fall of 1990 and required reporting of adverse licensure, hospital privilege and professional society actions relating to quality of care by physicians and dentists. According to one source, proposed rules adding other practitioners, including nurses, were published in March 2007.

Query:  does anyone know if those “proposed rules” were ever made into final rules?

The full scope of the legislative history, the awarding of three grants to the National Council of State Boards of Nursing by Robert Wood Johnson Foundation (RWJF) in excess of $1,000,000 between 1990 and 1997, the commendable activities of the National Council of State Boards of Nursing over many years to get better control and surveillance of licensure and ‘fitness’ to practice for nurses are all topics well beyond the scope of this blog.

Research is underway by our firm to determine the current status of federal legislation in this area as well as a myriad of other related topics – for example, what states boards of nursing do not yet have an agreement with the National Council?  What are the current requirements for timely reporting of adverse actions against nurses?  What legislation, if any, is pending to address this situation?  What other sad stories like that reported by these investigative writers are out there?

All the hard work to establish reporting guidelines and a national network for avoidance of these types of tragedies can not go for naught due to provincial and/or political interests that can result in serious harm to the public.

If you have any information about the current status of legislation or stories like that reported by ProPublica and others, let us know.