 | ||||||
 | ||||||
 | ||||||
I’ve been thinking about nurses, horses, guns, and hugs. We all were infuriated when we read about the man last March who walked into a Georgia hospital and shot a nurse he blamed for his mother's death. How could anyone do such a thing? Then I recalled a phrase from the Bible commenting on the human penchant for passing judgment on others while we do the very same things.1 Hardly anyone barges into hospitals like the man the AP article described as "armed with a three-year grudge and more guns than he could hold." But with nurses who have been involved in unintentional medication errors, do we "shoot our wounded?" We used guns of blame, with bullets of shame, and charges of felony in the case of Julie Thao, RN, of Madison, WI. Last week at The unSUMMIT for Bedside Barcoding, I had the privilege of interviewing Julie, who in the summer of 2006 mistakenly administered a drug via the wrong route to a 16-year-old mother in labor, causing the patient's death. Dr. Charles Denham, the founder and director of the Texas Medical Institute of Technology, was with us for the interview.
We talked about what went wrong. Look-alike mini-bags, common connectors, failure of a new bar-coding system, compensatory formalized work-arounds, and fatigue combined to result in simple, human-performance error. On the Fourth of July, Julie signed up for a second shift to cover for a coworker who had a family event. Following the double shift, Julie slept at the hospital because she was so fatigued, then worked a third shift to help alleviate the staff shortage.
So, I asked Julie why she volunteered? She told how nurses love what they do and how by nature they respond to requests for help.
The next day, I was pondering all this while watching the news about Eight Belles—runner-up of Kentucky Derby 134—falling just past the finish line after breaking both ankles. While vets euthanized the filly where she lay on the track, blogs were burning the ethers questioning the ethics of pushing thoroughbreds beyond their limits to snag purses for their owners and garlands for themselves. We won't let pilots fly, or truckers drive beyond their limits, yet we push our nurses to the point of exhaustion and error only to ditch them in their time of need. When Julie, who had helped develop her hospital's bereavement program, returned for pastoral care she was ordered her off the premises. Her colleagues had to consol her out on the sidewalk.
It all seems more hypocritical than Hippocratic to me. "With regard to diseases," wrote the venerable Greek physician, "make a habit of two things—to help, or at least to do no harm."2 To not help nurses at their point of need is to shoot them. So I asked my guests what a hospital's to do with nurses when they are involved in errors? Chuck and Julie responded by walking us through a landmark article on which they corroborated, entitled, "TRUST: The 5 Rights of the Second Victim." I urge you to download, read, and send it to your colleagues, C-suites, and board members. And what's a nurse to do when she is supposed to go home but only half of a shift shows up, and her coworkers beseech her to stay and ask, "Who is going to take care of the patients?"
Remember the setting of this interview—The unSUMMIT for Bedside Barcoding. Understandably, I had to ask: What do you think about point-of-care bar-code technology? Could it have saved your patient's life?
But Julie was not finished. She affirmed The unSUMMIT's conviction that while bar coding is the right thing to do; it must be done the right way. Her helpful advice is offered in my postscript below.
The late Henri Nouwen coined the term "the wounded healer" by which he referred to ministers who allow their wounds to become a major source of healing power. Julie is a wounded healer giving her life to nurses who have walked their wards in her shoes. She brings comfort to families who have experienced the loss of loved ones to medication errors. And, in spite of attempts to ban her from nursing, Julie continues her profession as a certified patient-safety officer by helping caregivers to avoid medication errors and hospitals to respond properly when errors occur.
What are we to do? I recently saw a faded bumper sticker: "Hug a Nurse." Reminds me of the Detroit Police Department's campaign calling for "Hugs not bullets." Is there a nurse you could shoot an e-mail, slip a note, or text message to in the next few minutes—sealed with hug? I suppose one could argue that there's no harm in silence. Then again...
What do you think? 1 Romans 2:3 2 Epidemics, Bk. I, Sect. XI P.S. The full interview will be streamed on pointofcareforum.com in the next week. Meanwhile, here is excellent advice from Julie Thao to hospitals considering bar coding at the point of care
To receive I've been thinking..." via email each month click here and put "IBT" in the subject box. | ||||||
 | | | | | | |
