Tag Archives: Nursing

Report details errors in waiting-room death

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

The Philadelphia Inquirer‘s Tom Avril reports on how hospital errors led to the death of a 63-year-old north Philadelphia guidance counselor. Avril opens his story by painting a picture of hospital operations, one based on documents released after a state investigation.

electronic medical recordsPhoto by exvertebrate via Flickr

Twice, when an emergency-room nurse called out the name of Joaquin Rivera and he did not respond, she had no idea he’d already suffered a massive heart attack.

The reason: The nurse did not venture beyond the waiting-room doorway and simply did not see him where he sat, unattended, for nearly an hour.

Avril reported that the hospital has already taken steps to prevent a similar occurrence in the future, including:

  • Increasing security by more than 30 percent
  • Creating new training for registration staff, with an emphasis on communication with nurses
  • Instituting a policy of calling patient names every 10 minutes if they don’t answer at first
  • Identifying a location on the waiting-room floor from which all parts of the room can be seen and marking it with tape so that triage nurses know where to stand when calling out names
  • Hiring an architectural firm to see if further improvements can be made

Problem nurses move from state to state

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

ProPublica’s Charles Ornstein and Tracy Weber have, with the help of the Los Angeles Times‘ Maloy Moore, released the final installment in their nurses series (full series: ProPublica | LA Times), this one focusing on how “caregivers with troubled records can cross state lines and work without restriction.” They found that a large number of these cross-state issues could be prevented if state regulators took advantage of readily available information.

By simply typing a nurse’s name into a national database, state officials can often find out within seconds whether the nurse has been sanctioned anywhere in the country and why. But some states don’t check regularly or at all.

The failure to act quickly in such cases has grave implications: Hospitals and other healthcare employers depend on state nursing boards to vouch for nurses’ fitness to practice.

The reporters found an army of examples, from the disturbing anecdote they lead with to the 117 California nurses whose licenses had been revoked, suspended, denied or surrendered elsewhere or the 10 nurses who were disciplined in Rhode Island, yet operated with clear licenses in neighboring Massachusetts.

Most of these transgressions are recorded in a federal database, as well as in one operated by the National Council of State Boards of Nursing. Both are incomplete, even though states are required to update the federal database within 30 days of a disciplinary action. And the federal database, while more complete, is rarely used, probably because it costs money while the state boards’ database is free. Some states only check these databases when licensing a nurse the first time, others rely on the nurses themselves to disclose their own problems. A handful check their nurse list against the database regularly, but they appear to be in the minority.

Nursing blog marks anniversary of landmark report

Pia Christensen

About Pia Christensen

Pia Christensen (@AHCJ_Pia) is the managing editor/online services for AHCJ. She manages the content and development of healthjournalism.org, coordinates AHCJ's social media efforts and edits and manages production of association guides, programs and newsletters.

In a two-week series of posts, the INQRI blog – the blog of the Interdisciplinary Nursing Quality Research Initiative – is recognizing the 10th anniversary of “To Err is Human,” the groundbreaking report that found that as many as 98,000 people die each year from medical errors in hospitals.

A nurse vaccinates a child in this CDC photo.

A nurse vaccinates a child in this CDC photo.

The latest post, written by Barbara Olson of Florence dot com, looks at the building blocks of better health care. She says that ten years of studying how to make health care reliable has revealed that “things like speaking clearly, repeating words to be certain they have been understood; taking turns; using “inside” voices; and getting plenty of rest matter when individuals rely on complex processes to deliver intended outcomes. (Even “time-outs” have made a comeback!)”

Earlier posts include a Q&A with Paul Levy, president and CEO of Beth Israel Deaconess Medical Center in Boston; one that warns that we may not have made much progress in the area of patient safety; and a post about a nurse researcher who has found that a positive work environment helps nurses catch errors before they harm patients.

Calif. adopts strict rehab rules for medical workers

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

ProPublica reporters Tracy Weber and Charles Ornstein have filed a report (Los Angeles Times version, ProPublica version) on the fallout from their work exposing failures in California’s nurse rehab program.

The state has adopted strict new rules governing drug abusers in the health care industry, requiring that those in the rehab program be tested more than 100 times in the first year, and pulling them from practice immediately should a relapse be detected.

In addition, public Web sites will now list any restrictions to their licenses, “easing the long-standing confidentiality protections that have shielded participants and kept their patients in the dark.”

Slip of the needle brings fallout, tough decisions

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

Writing for The New York Times, AHCJ member Sibyl Shalo Wilmont shares the chain of events that followed when she accidentally injected herself with a drop of a patient’s blood.

needle
Photo by hitthatswitch via Flickr.

A quick test showed the patient was likely negative for HIV, but Wilmont still had to decide whether or not to undergo post-exposure prophylaxis, a grueling cycle of treatment that would continue for at least a month. Wilmont had covered post-exposure prophylaxis as a journalist and her knowledge for that helped guide her decision.

Calif. nurse rehab program full of holes

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

ProPublica’s Tracy Weber and Charles Ornstein follow up their investigation of California’s nursing oversight with a story about the failures of the state’s nurse rehab program (Los Angeles Times version; ProPublica version). The embattled California Board of Registered Nursing has touted the program as a safe haven where otherwise good nurses can free themselves of bad habits, but Weber and Ornstein have discovered that nurses often don’t complete the program, and sometimes continue bad behavior unabated despite the voluntary, confidential program’s required drug tests and treatment.

The team has reinforced its data-driven story with well-chosen anecdotes and observations. Program proponents argue that Weber and Ornstein are focusing on a few failures and ignoring the more numerous success stories, but the reporters show that the failures are due, at least in part, to flaws in the program. Even nurses designated as a “public risk” often aren’t investigated until more than year after earning that dubious distinction.

The reporters’ sum up the problem thus: “At the moment, the main person responsible for protecting the public from a drug-addicted nurse in California is the drug-addicted nurse. It’s a risky honor system.”