According to a report released this week, medical errors in hospitals are the third leading
cause of death in the US. That figure, according to some, does not represent the entirety of the problem because there is no diagnosis code for medical errors. Some people (lawyers?) are suggesting that a check mark be placed on death certificates to indicate if a preventable error contributed to the death of a patient. Wait for that to happen.
Meanwhile, think of all the highly trained healthcare professionals, avant garde technology and elaborately engineered systems that are in place when a hospitalized patient dies from a medical error. Now think of the homes and families of many of your patients with multiple caregivers who are not employed in the healthcare industry and whose homes were not built according to the life safety code. Can you see why patient safety might should move up on the home health and hospice priority lists? Here are three examples I can think of off the top of my head.
- Several years ago, a patient with newly diagnosed pancreatic cancer decided to forego treatment and enjoy his final days with his family. Upon admission to hospice, the nurse brought to the home a standard Emergency Kit to the home. Instructions on how and when to use the (and so much more) were reviewed with a family who just learned that their loved one was dying. Later, a grown son was investigating the contents and saw the sublingual morphine to be given every 30 minutes PRN pain. Regrettably, he interpreted PRN to mean Prevent. Ever the good son, he gave his father sublingual morphine every thirty minutes. The patient died before morning.
- A home health patient was having continued blood pressure problems despite the fact that he was taking his meds as ordered. The physician increased his meds from 5 mg to 10 mg but the pharmacy was out of 10 mg pills. The patient was told to take two 5 mg pills until the 10 mg pills were available. A few days later, a family member picked up the new meds and the patient continued two of the pills resulting in a nice but very pricey visit with the local Emergency Room.
- A client was called on the carpet by a physician after a post ORIF patient was admitted to the hospital with an INR greater than 8. The nurse taking care of the patient was quick to point out that there were no orders to draw an INR and she vaguely recalled asking for an order but didn’t get one.
I bet with your help, we could make a list of errors that would take up the whole internet. That probably wouldn’t prevent future errors, though.
Finding fault with others is a common response but it is useless because you have limited control over others. The son who gave the sublingual morphine should have called if there were any questions. The patient with high blood pressure was told that he was only taking 5 mg pills until the new pills came arrived. The physician needs to order INRs if he or she wants nurses to draw them. The underlying logic seems to be that since you have ten fingers, you might as well use one of them to point.
In order for an agency to make a lasting difference and prevent future errors, the clinical staff as a group should ask, ‘What could the agency have done differently?’ Read carefully because there is a world of difference between asking what the agency could have done differently and finding out who’s at fault. Changing a process does not imply that there was anything wrong with a prior process.
There is nothing to indicate that the hospice nurse who carried the Emergency Kit to the home did not follow agency policy or provided bad information to the patient. The family was devastated and the nurse found herself in a very high stress situation. Good hospice nurses can come up with different ways to get an E-Kit out to a patient’s home safely. The policy should be that patients will have an E-Kit available to provide for times when pain is severe. The processes may change according to how the patient is assessed and what the home environment is like. So much goes into that small decision that a mere consultant couldn’t make it for you in a blog but hospice nurses are good. They are creative by necessity and will find ways to do things that have never been documented in a policy for wide spread use.
The poor gentleman who overdosed on antihypertensives was unable to read and forgetful. Knowing this and sharing the information with the physician and the pharmacist and others involved in the care of the patient might have encouraged them to put mechanisms in place. I’m quite certain the family and patient were taught how to take the meds (as ordered). What matters is that there has to a better approach that doesn’t result in emergent care. Do you think additional visits might have been ordered until the patient was once again stable on meds? Use your 20/20 hindsight as a guide in looking forward the next time.
The INR seems like it might be a physician problem but think again. Your agency agreed to admit a patient on a powerful anticoagulant. You are not the boss of the doctor (except in dreams that could be the stuff of a crazy reality show). If the physician does not want the agency to draw INRs, ask for copies of the lab from the physician’s office. If the physician can’t be bothered to send them, be sure to write, ‘INRs to be drawn at MD’s office per physician preference’ on the 485. Underline this notation when the plan of care is sent to the MD. This will at least cover you if someone tries to throw you under the proverbial bus. You can also ask the patient or family member to find out what the lab is and report it to you. Mostly, you should consider if you want to accept future patients from a physician who does not share information required to adequately care for the patient.
If a patient is harmed or a series of events transpired that may have caused harm, a discussion should take place. If ideas are openly solicited, you may be surprised to find out what that the quiet one who sits in the corner thinks or what the CNA overheard at the house that might shed light on an accident waiting to happen. Investigate the events. If a clinician appears to be underlying cause, don’t stop there. Was he or she oriented properly? Is the agency’s competency tests up to date? How many visits was the nurse making? How much clinical education is the staff getting. Are there other clinicians who might similarly be inexperienced or overworked and apt to cause the same error? The solution to a problem is rarely to fire someone. Finding solutions is not about finding scapegoats.
Maybe the most important step in improving patient safety in home health is to take off the blinders. If you are able to recognize where an opportunity to prevent an error lied in past occurrences, it will be easier to see in future occurrences. Taking responsibility does not always mean accepting blame. It means you are willing to step back and broaden your vantage point to find opportunities. We owe it to our patients to try and we owe it to ourselves to quit being so complacent about patient harm that is not our fault.