Recently, I spoke with a reporter from one of our Western States. She had reached out to the members of our health care journalist list asking for feedback on the Magnet Hospital program. As a columnist I shared with her both my personal and professional opinion (note to readers a columnist is entitled to an opinion, while a reporter is charged with reporting the facts). As our conversation drew to a close the reporter commented that she was somewhat surprised when this particular hospital became a Magnet hospital, since in their community it is considered the worst of the two hospitals their town has to offer. My point exactly, I told her that is why among nurses the significance of “Magnet” status can be and continues to be so hotly debated. Why do nurses seem to be so divided on this issue? You’d think that nurses would rally around the Magnet program, but in reality many nurses view the Magnet Hosptial designation with suspicion and trepidation, while others welcome it with open arms and sing its praises. Why?
The Magnet Hospital designation has been promoted as the “gold” standard for a hospital’s nursing staff much like achieving Joint Commission (formally JCAHO) is considered the proverbial “Good Housekeeping Seal of Approval” for hospitals. The American Nurses Credentialing Center (ANCC) (a sub-organization of the American Nurses Association [ANA]) created the Magnet Recognition Program. The objectives are simple and make for a persuasive argument for seeking such recognition. These objectives are:
➢ Recognize nursing services that use the Scope and Standards for Nurse Administrators (ANA, 2003) to build programs of nursing excellence for the delivery of nursing care to patients
➢ Promote quality in a milieu that supports professional nursing practice
➢ Provide a vehicle for the dissemination of successful nursing practices and strategies among health care organizations using the services of registered professional nurses
➢ Promote positive patient outcome
As my children are fond of saying, it doesn’t take a rocket scientist to realize that the above objectives are not only admirable but objectives that all nursing teams, whether at a hospital, clinic, or doctor’s office, should want to achieve. The question that one must ask is whether or not this program is achieving the goals that they promote, or is it yet another program that is run and defined by paperwork, achieving a “magic” number, and generating revenue for an outside organization?
Nurses are very much divided when it comes to the value of a hospital seeking Magnet Hospital designation. In the Los Angeles and Orange County area there are only four and three hospitals, respectfully, that have been granted “Magnet” status. One in LA has a chronic nursing shortage, a second made the local news and not in a good way for problems that can be laid at the feet of the nursing staff. Hospitals trumpet far and wide when they receive their “Magnet” designation, and to my knowledge only one hospital, UC Davis Medical Center, has ever had its designation removed. After a recent and well publicized medication error occurred at a local area hospital a journalist posted a question to our mailing list asking what if anything happens to the Magnet status that had been awarded in such as case, or after a hospital received State sanctions or fines? Did the ANCC place the hospital in probation, did they reassess, did they publicize when a hospital looses its Magnet recognition? I found the response provided by another list member who is also involved with the ANCC rather shocking, but indicative of why so many of my fellow nurses take the vaunted “Magnet” designation with such a grain of salt. Her response was that the ANCC did nothing in such cases and that it was up to the hospital to “inform” the public. Such a passive position, in my opinion, only reaffirms the suspicion of many nurses that the Magnet designation is just one more scheme to generate funds to an outside agency and to see how many hoops they can make the nursing staff go through to please some “nameless” accrediting body. My readers may find this statement overly harsh, but as a registered nurse who prides herself as a professional and who has never worked in a “Magnet” designated hospital but who has had the privilege to work in many stellar hospitals during her career it offends me when a credentialing agency promotes a “seal of approval”, setting one hospital above another and then when one of their “meets a higher” standard hospital fails to maintain this goal does nothing to place that institution in a probationary status, require review before reaffirming the “seal of approval” or outright revocation of the “seal of approval”. This type of behavior only provides more reasons for nurses to be suspicious of the validity of such a program.
Does this mean that such a “seal of approval” should be designed or furthered? Hardly, nurses share the common desire of other professionals to have the organization they work for be recognized for outstanding performance, and having a specific segment (such as nursing) singled out even furthers a feeling of pride in one’s institution, team and self. Unfortunately, like with so many “seals of approval” they are more often than not a paper tiger. I know that many supporters of the Magnet recognition program often express frustration and bewilderment when nurses, such as myself, show a profound lack of acceptance and respect for this program and its lofty goals. However, I believe that the skepticism is justified and warranted based on our experience either working in such institutions, knowing the overall character/skills of the nursing staff at some of these organizations, and in some cases having been a patient or knowing someone who has been cared for by the nursing staff at these “Magnet” designated hospitals. A common complaint that I hear from nurses that have both experienced the evaluation process or worked within a Magnet hospital is that once the Magnet recognition is received by the hospital the staff, administration and hospital often pretty much fall back into their old routines and thus making the positive changes set forth by the Magnet program moot in many cases. Many nurses often express the same opinion and frustration with the Joint Commission process.
I know that supporters of the Magnet recognition program will often cite published research that support the assertion that hospitals with Magnet recognition are “better” at attracting and keeping quality nurses and that this then translates to better patient outcomes. Without a doubt reading such articles, and I read the many that come across my desk, one has to also balance such studies with the bias (and we all have them) that the researchers, their funders, and yes the publications may have and how this may affect the outcomes. One way to deduce the potential for bias is to know the author of the paper and their institutions, another is to request the study tool that was designed and utilized. This does not mean that such studies are inherently flawed, on the contrary they may be well designed but by educating yourself on what the assumptions were in designing the study that lead to the published outcomes can help you understand how the conclusions were derived. My son, an actor/independent film-maker, likes to remind me that even documentaries have an inherent bias, because the moment the director chooses which angle to shoot from, where to plant the camera, or which scenes to cut or not cut the documentary becomes biased.
Could a program such as Magnet recognition serve as a marker of distinction, without a doubt? However, I think the program as it is currently used, and implemented has many flaws that the ANCC continues to turn a blind eye to and the most serious flaw is what to do when a hospital’s nursing staff turns out to be less than the exceptional model set forth in the goals of the Magnet Recognition program. Nurses who participate in the evaluation and accreditation process need to be able to attach a value to the entire program, and one way to achieve this is for the ANCC to also publicize when a hospital that has been designated a Magnet fails to maintain the highest expectations of the organization and the credentialing program. For example when UC Davis lost its Magnet recognition designation the local newspaper reported that the ANCC had taken this action in part because of the unionization of the hospital (when UC Davis had initially received the designation it was non-union), and had responded to calls from the nursing team that had contacted the ANCC independently. The logic was that if the nurses felt the need to seek union representation that this must mean that the nursing structure was not fulfilling the fundamental goals set forth by the Magnet program, and thus they decided to remove the Magnet recognition, which to this day UC Davis has failed to recapture (though they may have chosen to reapply). The union argued that the removal was arbitrary and unwarranted, and on the one hand they have a point since the fact that it was the nurses working as a team chose to contact the ANCC does somewhat validate some of the core principals of the Magnet recognition program.
I see the potential of the Magnet program, however in its current incarnation I also think that it is far too often a “soft” tool and has too much of a subjective appearance, much like so many of the other “this is a great hospital” programs available today. Programs with the lofty goals, such as the Magnet Recognition, really need to also have some teeth, so that once the recognition is achieved the hospital and nursing administration and nursing team know that they cannot allow any falling back into the way it was or else they risk loosing this very unique and rare designation. As the near-tragic Heparin overdose occurrences at Cedars-Sinai Hospital in December of last year, a quick search of the ANCC website shows that Cedars still retains its Magnet designation. One would think that the near fatal overdosing of three infants, the admission of the break down in procedure by the hospital administration, the findings from the State that Cedars failed to implement its own policy, hefty fine, and the admission of the nurses that they did not read the information on the vial would warrant at least a probationary status or a re-evaluation. One may think this rationale overly harsh, I think not. If we are to accept that Magnet Recognition is the epitome of what the nursing profession can and should aspire to, that hospitals that pay large sums of money to go through such a recognition process and meeting the set goals in order to recognized as an institution that has enshrined these ideals and put them into practice; then in turn when such an institution fails to uphold or continue to meet this standard there should be serious repercussions.
Otherwise examples such as these leave nurses with the feeling that Magnet Recognition is more myth then reality – and it doesn’t have to be that way.
Showing posts with label heparin. Show all posts
Showing posts with label heparin. Show all posts
Wednesday, April 9, 2008
Sunday, November 25, 2007
Endangering the patient . . .
Earlier this month a medication error was reported at Cedars-Sinai Hospital. The television show “TMZ” (The Thirty Mile Zone) first broke the news of this error, since it involved the children of a celebrity. The error, as it was reported, involved the unintentional overdosing of three infants (though other sources have reported that the incident may have involved up to 13 infants) with a Heparin overdose. Two of the infants that were affected by this medication error are the twin infants of Dennis Quaid and wife Kimberly Buffington.
As of today, Nov. 25, 2007, there seems to be several conflicting stories, so I’ll start with the initial report. TMZ broke the news with the following general information; three infants received inadvertent overdoses of Heparin, used to flush IV lines. They reported that two separate doses of 10,000 u were administered: the first was on Saturday and the second 10,000 u was on Sunday; and that the error was caught when the nurses noticed that the infants were beginning to “bleed-out”. The drug Protamine, the anti-dote to the Heparin overdose, was administered and the children were in Neonatal intensive care (NICU). Cedars later issued a press release that characterized the incident as an error that occurred due to a technician inadvertently placing the high concentration 10,000 u vial of Heparin (usually used in adults only) in the unit’s pharmacy stock, the nurse accustomed to only one dosage type (the lower concentration vial of 10 u) being available grabbed the high concentration vial and administered the incorrect amount, the nurses realized an error had occurred, ran the test to confirm their suspicions and then administered the anti-dote, Protamine. The hospital admitted that the error occurred in part because the nurse did not follow hospital protocols and procedures and that the State of California Department of Health and Human Services was investigating the incident. It has also been reported that the infants were in stable condition and had suffered no ill effects.
In my opinion the most interesting coverage about this unfortunate, but preventable, error came courtesy of the Los Angeles Times. Their coverage appears to me to be an almost “kid glove” handling of this very serious medication error and breech of nursing practice. Let’s not forget that Cedars is suppose to be a “Best of the Best Hospital” and a Magnet Hospital and the list of so-called “excellent” hospital awards goes on, so for such a medication error to occur should have news agencies asking the tough questions. Instead, news agencies seem to be happy to regurgitate the Cedars press release and to “downplay” the incident by spinning it as medications errors in hospitals are not uncommon. When a similar incident occurred at the now defunct King/Drew Medical Center several years ago the LA Times, rightly so, reported heavily on the hospital’s failure to safeguard their patients from medication errors; but they seem unwilling to use the same journalistic scrutiny on Cedars during this incident. The first Los Angeles Times’ article, which ran the day after the story broke on TMZ seemed to be mostly a regurgitation of the information provided by the Quaid/Buffington family, TMZ and the Cedars-Sinai Hospital authorized press release with no real new information provided. The second story, which ran the next day, in the Los Angeles Times tried to convince its readers that hospital drug errors were not uncommon; and if we believe this then we should be very concerned about the state of nursing and medicine in our Nation’s hospitals. What the Los Angeles Times failed to mention or question was how could such a medication error and failure of basic nursing practice occur in a hospital that proudly displays its US News America’s Best Hospital 2007 award and that it has been awarded the American Nurses Credentialing Center’s (ANCC) Magnet Excellence in Nursing status. Cedars even proudly displays this statement from the ANCC on its website “The ANCC found that Cedars-Sinai's nursing services "represent the highest standards in the nation and internationally." I would have to say that the recent Heparin overdose incident puts this label into question. But then again most RNs think that both Joint Commission and Magnet status are “jokes” and more often representative of how well hospitals prepare and present their documentation and how they “play” to their surveyors then an actual representation as to the quality of care and the nursing staff.
As a RN with over 35 year of experience at both the bedside and in nursing management and education I find the nursing error at Cedars frightening, but not completely surprising. Why, because I am very familiar with this particular hospital and the caliber of its nursing staff. And though there are many good nurses at Cedars, I also know that the nursing staff as a whole has not always been at the peak of their game (also using many registry and traveler RNs). The past several years have seen at least two, ugly, but failed unionization attempts of the nursing staff. These attempts have taken their toll on the staff and have left many nurses feeling angry and betrayed by one or the other side. I know that at least one unit, which once had a very stable staff, has experienced a great deal of turn-over recently, and this turn-over has left the remaining staff feeling unsupported by nursing management, and in many cases feeling demoralized and burnt-out.
As recently as four weeks ago, a neighbor and nurse, was admitted at Cedars for surgery and when she returned she spoke of a very poorly run nursing staff and a care-environment that was anything but caring. What gave her great concern was the lack of English exhibited by the nurses in the clinical setting. She said during her entire stay that she very seldom heard a word of English spoken in her presence (she is an English speaker) and she was concerned that if their English was so poor that they had to communicate to one another in their common “native” language then how well did they comprehend orders that were given in both verbally and in writing in English.
However, as a RN, what concerns me greatly is the failure of the nurse to follow the most basic of nursing protocols and that is to always check the medication (and that means reading the label). We work in a field that is not only high-stress but prone to human error and it is for this reason we are taught to rely on our eyes to verify such things as: is it the right medication, the right dosage, etc. The excuse given that “the nurse was unaccustomed to more than one type of heparin vial” is a poor one.
This past April I covered the issue of medication errors for my column From the Floor, which is published every three weeks in Working Nurse Magazine. My article can be found by following this link http://www.solutionsoutsidethebox.net/articles___studies. In this article I spoke of a medication error that cost a young mother her life and left her newborn an orphan and how medication errors occur and what nursing and hospitals can do to minimize and reduce situations that give rise to errors of this magnitude. There is a current trend in nursing and medicine to practice what has been labeled “blameless medication errors” the premise of this method is that if we do not “blame the nurse” for a error then the nurse will be more forthcoming when an error occurs thus allowing the error to be addressed and a correction plan implemented. However, the downside to “blameless medication error” reporting is that there may very well be an incident in which protocols and practices have been violated in such a way that blame should be assigned, as in the case of outright negligence.
What concerns me about the Heparin incident at Cedars is that 1.) This is not the first time this type of error has occurred, 2.) There was an FDA warning issued about the possibilities of such incidents, 3.) No one double-checked the vial to ensure it was the right medication or dose, 4.) The conflicting reports that first there were two overdoses versus just the one, 5.) First reports provided different facts as to how the overdose was caught, 6.) Reports seem to vary greatly as to how many infants were actually given the Heparin overdose and 7.) The report that there have been no ill-affects, when any NICU nurse or physician knows that it could be weeks to months before we learn if the children who received the overdoses will suffer from any negative sequelae.
Yes, this was indeed a culmination of a series of human errors, however as nurses one of our jobs is to serve as the patient advocate, which sometimes translates into the last line of defense. In the end there should have been two nurses whose job it was to ensure that the patient received the correct medication and dosage. The nurse whose job was to administer the medication should have had another nurse check the order, the vial for appropriate drug and dosage (it was never stated if another nurse had check the dosage and drug). This failure to practice what is a most basic of nursing skills has caused several infant lives to be endangered, families to be traumatized; and for the nurses and the staff involved this may very well be a career ending event. Let’s hope that this time we learn the lesson so that no other infant is placed in this type of preventable medical jeopardy – again!
As of today, Nov. 25, 2007, there seems to be several conflicting stories, so I’ll start with the initial report. TMZ broke the news with the following general information; three infants received inadvertent overdoses of Heparin, used to flush IV lines. They reported that two separate doses of 10,000 u were administered: the first was on Saturday and the second 10,000 u was on Sunday; and that the error was caught when the nurses noticed that the infants were beginning to “bleed-out”. The drug Protamine, the anti-dote to the Heparin overdose, was administered and the children were in Neonatal intensive care (NICU). Cedars later issued a press release that characterized the incident as an error that occurred due to a technician inadvertently placing the high concentration 10,000 u vial of Heparin (usually used in adults only) in the unit’s pharmacy stock, the nurse accustomed to only one dosage type (the lower concentration vial of 10 u) being available grabbed the high concentration vial and administered the incorrect amount, the nurses realized an error had occurred, ran the test to confirm their suspicions and then administered the anti-dote, Protamine. The hospital admitted that the error occurred in part because the nurse did not follow hospital protocols and procedures and that the State of California Department of Health and Human Services was investigating the incident. It has also been reported that the infants were in stable condition and had suffered no ill effects.
In my opinion the most interesting coverage about this unfortunate, but preventable, error came courtesy of the Los Angeles Times. Their coverage appears to me to be an almost “kid glove” handling of this very serious medication error and breech of nursing practice. Let’s not forget that Cedars is suppose to be a “Best of the Best Hospital” and a Magnet Hospital and the list of so-called “excellent” hospital awards goes on, so for such a medication error to occur should have news agencies asking the tough questions. Instead, news agencies seem to be happy to regurgitate the Cedars press release and to “downplay” the incident by spinning it as medications errors in hospitals are not uncommon. When a similar incident occurred at the now defunct King/Drew Medical Center several years ago the LA Times, rightly so, reported heavily on the hospital’s failure to safeguard their patients from medication errors; but they seem unwilling to use the same journalistic scrutiny on Cedars during this incident. The first Los Angeles Times’ article, which ran the day after the story broke on TMZ seemed to be mostly a regurgitation of the information provided by the Quaid/Buffington family, TMZ and the Cedars-Sinai Hospital authorized press release with no real new information provided. The second story, which ran the next day, in the Los Angeles Times tried to convince its readers that hospital drug errors were not uncommon; and if we believe this then we should be very concerned about the state of nursing and medicine in our Nation’s hospitals. What the Los Angeles Times failed to mention or question was how could such a medication error and failure of basic nursing practice occur in a hospital that proudly displays its US News America’s Best Hospital 2007 award and that it has been awarded the American Nurses Credentialing Center’s (ANCC) Magnet Excellence in Nursing status. Cedars even proudly displays this statement from the ANCC on its website “The ANCC found that Cedars-Sinai's nursing services "represent the highest standards in the nation and internationally." I would have to say that the recent Heparin overdose incident puts this label into question. But then again most RNs think that both Joint Commission and Magnet status are “jokes” and more often representative of how well hospitals prepare and present their documentation and how they “play” to their surveyors then an actual representation as to the quality of care and the nursing staff.
As a RN with over 35 year of experience at both the bedside and in nursing management and education I find the nursing error at Cedars frightening, but not completely surprising. Why, because I am very familiar with this particular hospital and the caliber of its nursing staff. And though there are many good nurses at Cedars, I also know that the nursing staff as a whole has not always been at the peak of their game (also using many registry and traveler RNs). The past several years have seen at least two, ugly, but failed unionization attempts of the nursing staff. These attempts have taken their toll on the staff and have left many nurses feeling angry and betrayed by one or the other side. I know that at least one unit, which once had a very stable staff, has experienced a great deal of turn-over recently, and this turn-over has left the remaining staff feeling unsupported by nursing management, and in many cases feeling demoralized and burnt-out.
As recently as four weeks ago, a neighbor and nurse, was admitted at Cedars for surgery and when she returned she spoke of a very poorly run nursing staff and a care-environment that was anything but caring. What gave her great concern was the lack of English exhibited by the nurses in the clinical setting. She said during her entire stay that she very seldom heard a word of English spoken in her presence (she is an English speaker) and she was concerned that if their English was so poor that they had to communicate to one another in their common “native” language then how well did they comprehend orders that were given in both verbally and in writing in English.
However, as a RN, what concerns me greatly is the failure of the nurse to follow the most basic of nursing protocols and that is to always check the medication (and that means reading the label). We work in a field that is not only high-stress but prone to human error and it is for this reason we are taught to rely on our eyes to verify such things as: is it the right medication, the right dosage, etc. The excuse given that “the nurse was unaccustomed to more than one type of heparin vial” is a poor one.
This past April I covered the issue of medication errors for my column From the Floor, which is published every three weeks in Working Nurse Magazine. My article can be found by following this link http://www.solutionsoutsidethebox.net/articles___studies. In this article I spoke of a medication error that cost a young mother her life and left her newborn an orphan and how medication errors occur and what nursing and hospitals can do to minimize and reduce situations that give rise to errors of this magnitude. There is a current trend in nursing and medicine to practice what has been labeled “blameless medication errors” the premise of this method is that if we do not “blame the nurse” for a error then the nurse will be more forthcoming when an error occurs thus allowing the error to be addressed and a correction plan implemented. However, the downside to “blameless medication error” reporting is that there may very well be an incident in which protocols and practices have been violated in such a way that blame should be assigned, as in the case of outright negligence.
What concerns me about the Heparin incident at Cedars is that 1.) This is not the first time this type of error has occurred, 2.) There was an FDA warning issued about the possibilities of such incidents, 3.) No one double-checked the vial to ensure it was the right medication or dose, 4.) The conflicting reports that first there were two overdoses versus just the one, 5.) First reports provided different facts as to how the overdose was caught, 6.) Reports seem to vary greatly as to how many infants were actually given the Heparin overdose and 7.) The report that there have been no ill-affects, when any NICU nurse or physician knows that it could be weeks to months before we learn if the children who received the overdoses will suffer from any negative sequelae.
Yes, this was indeed a culmination of a series of human errors, however as nurses one of our jobs is to serve as the patient advocate, which sometimes translates into the last line of defense. In the end there should have been two nurses whose job it was to ensure that the patient received the correct medication and dosage. The nurse whose job was to administer the medication should have had another nurse check the order, the vial for appropriate drug and dosage (it was never stated if another nurse had check the dosage and drug). This failure to practice what is a most basic of nursing skills has caused several infant lives to be endangered, families to be traumatized; and for the nurses and the staff involved this may very well be a career ending event. Let’s hope that this time we learn the lesson so that no other infant is placed in this type of preventable medical jeopardy – again!
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