Caught with Their Pants Down!

Failure to Address Systemic Problems Causes Medical Errors to Continue – A Shocking Revelation!

When we started working on the implementation of solutions to solve systemic problems three years ago, it was evident problems would be encountered since we were dealing with people and not machines. However, it was shocking to see the type of battles we faced. In one of the institutions in our study, we encountered barriers which precluded the implementation of corrective actions to solve problems. Later, we also realized that one of the reasons why major initiatives failed was due to human resistance to change. We had started the lab-nursing committee to address the problems between these two departments and to help the nursing department fix the large number of specimen collection errors. It was a meeting based on the principles of continuous quality improvement – C.Q.I. The lab tried many strategies for three years to help the nursing department solve the problem, but nothing worked. The lab continued to hit the brick wall in part because the nursing representatives refused to follow the principles of C.Q.I. at the meetings. Even if the nursing department wanted to correctly train the staff, there were still some lab procedures that had to be taught by the lab staff. The nursing representatives at the meeting indicated they did not know what was going on or why the number of specimen collection errors was so high. So, we all believed that the major problem was resistance to following instructions.

Every effort was therefore designed to impact changes directly through those who were drawing blood. The lab had even joined the Nursing Blitz Days for the past three years to update nursing staff about specimen collection during their yearly recertification. Despite the revelation after the Blitz days that many of the nursing staff members needed conventional education and training on phlebotomy and specimen collection, the nursing department refused to support such an effort. During the recertification program, some of the nursing staff begged us to give them more detailed education and training. One of them was in tears, begging for more information and training during the Blitz days since we only had about four minutes with each participant. The nursing director was unimpressed, even though the reports from the Blitz days were made known to her and her representatives. Every effort of the lab to schedule an educational program with the nursing staff was blocked by the nursing department. In one of our meetings, the problems were inadvertently exposed by one of the frustrated nursing managers who had just joined the committee. He complained about the problems within nursing that made solution implementation difficult. He was about to open a Pandora’s box that the nurses had been hiding for so long!

Serious Training Problems within the Nursing Department

Before the revelation of the nursing manager, the institution under question had a specimen collection error rate much higher than the national average. It was not unusual to record over 1,000 specimen collection errors in a year, each of them carrying the potential to harm a patient. This situation was created in part because blood collection that used to be done by lab was taken over by the nursing staff. For the past three years since this committee between the lab and the nursing department started, the committee was falsely given the impression by the nursing department that all those who were drawing blood and collecting specimens from patients were adequately trained. The committee was trying to address why there were so many specimen collection errors if these workers were adequately trained. After working three years and hitting our heads against the walls while trying for find the cause of the problems, one of the nursing representatives inadvertently told the committee the cause of the problems during our July 2002 meeting.

According to the representative, a problem was created when those who were hired to draw blood were allowed to work without being trained. They were supposed to be scheduled for training six months after they had been working on the floor. This change was a very unwise decision that created a lot of problems. Because of the change, it was difficult for the nurse managers to schedule some of the workers for training. In some situations, people were hired and worked for a year on the floor, but were never trained to collect blood. To add more to the problems, the nurse managers who assigned people to duties at the nursing stations did not know who was trained and who was not trained to draw blood. Since this nursing department has a high turnover rate, only God knows how many workers are drawing blood without training. Although the lab staff heard of the stories of untrained people being asked to draw blood, we thought they were anecdotal incidents. Consequently, this problem was directly responsible for the dangerously high number of specimen collection errors by the nursing staff. It appeared as though the false statement made by the nursing department for three years was a deliberate act of deceiving the committee to hide the systemic problems within nursing. This was very unethical because wasted time and efforts were spent for years on issues that were unrelated to the specimen collection problems! The fact was specimen collection errors were so high in this particular institution because those who were drawing blood were never given adequate training to do the job.

Resistance to Change

Prior to exposing the problems, the lab tried to convince the nursing representatives that standardized education was needed for all their staff drawing blood. The high error rate was unacceptably dangerous! The nursing department, championed by the vice president of nursing, refused. Repeated attempts were made over the years to convince the nursing department to change their style of educating their staff, but they refused. At one time an article was given to the director of nursing about how other hospitals solved the problem of specimen collection with the laboratory department being a key participant. It did not help. Most annoyingly, the same vice president of nursing came to the meeting one day and gave the committee a long speech on why educating the staff should not be the only option. Many times, the committee was told by the nursing representative that education was not needed. But, education had not been tried! Sometimes you wonder how people get the executive jobs if they are unable to apply common sense.

 Nursing Dept. Blames the Lab for Everything

From the beginning of this project, the nursing department had continued to blame the lab for many of the problems of specimen collection. Based on the report after evaluating about 500 nursing staff in this particular institution, 90 percent of them believed that lab was responsible for causing blood to clot. They could not understand that their poor procedure of not mixing the blood properly with anticoagulant immediately after collection was majorly responsible for many clotted specimens. One time, the nursing department thought the lab was playing games by turning off the pneumatic-tube system to prevent specimens from coming to the lab from the nursing stations. The truth was, when the system was congested, the jam caused the system to shut down. The nursing department was embarrassed when it realized there was no way for the lab to turn off the tube system.

It was also discovered that many of the nurses did not understand the lab’s common procedures. Evidence also indicated that some of the nurses did not know how to use the computer system. Instead of the nursing service adequately training their staff to obtain results from the hospital computer, the laboratory would receive repeated calls for test results that were already completed. The lab would sometimes receive calls from nursing staff who could use the computer. They would be asking for test results that were already resulted. When they were asked, why they were calling the lab for this information, the response was, “It’s easier to call the lab and get results than look for the results in the computer.” While the lab is busy trying to answer all these ridiculous calls the same nursing department is worried about the turn-around time for test results. They were totally oblivious to the fact that they were in part responsible for the delays in reporting tests due to all the telephone call interruptions and the multitudes of problems created for the lab by the nursing department. When a nursing department has so many bad systemic problems and refuses to fix them, one can only wonder how many patients become victimized.

 Problem Resolution

Nursing managers will improve their rate of specimen collection errors if they admit they have training problems and deal directly with the issue instead of blaming the lab for all their problems. This is not to imply that the particular lab in this hospital did not have problems. But, the greatest burden of responsibility is on the shoulders of a nursing administration that refused to admit to the inherent problems within their system! The deception and fraud they perpetuated over the years regarding the training of their staff in specimen collection is very unethical and very disappointing indeed!

When the lab and nursing committee first started, the director of nursing spent almost two years fighting over the data collected by the lab. Her fight was a distraction from the real problem. It had nothing to do with the specimen collection problems. At that time, she indicated that the lab had inflated the numbers to make the nursing department look bad. It was explained to her that it only took one error to kill one patient. Instead of dealing with the problems which resulted form their bad training, they side-stepped the real issue and attacked the lab! For the nursing department, it was easier for the managers to blame the lab for their problems instead of dealing with the problems within their department. The nurses attempted to diminish the danger of specimen collection by telling the lab that 1,000 specimen collection errors per year were not that bad. While the nursing department rejected the data collected by the laboratory, it developed its own way to count errors and most of the time underestimated the number of errors compared to the lab’s numbers. They tried their best to convince the lab that the number of errors were not that bad until we start counting dead patients. That was what they were trying to prove as they manipulated the number of specimen collection errors to make it look smaller. Each time they produce any statistics or graph, their numbers were always smaller. Who were they trying to fool? During the three years of study, many misidentified and unlabeled blood and pathology specimens were received from the nursing department, including four near-miss-situations where emergency room patients almost received the wrong blood. The lab caught most of the errors. How about the errors that were not obvious, and the patients who were harmed as a result? How many patients have died as a result of errors in this institution?

 To solve this problem, the nursing department must be able to admit to its own errors. In many situations, the laboratory is persecuted for errors made by the nurses. Will the nursing department admit to this problems and work to fix them? In this particular hospital some people were saying that the director of nursing should be given the benefit of the doubt in case she did not know what was going on with the education process of her employees. In such a case, she is negligent since it is part of her responsibility to be sure all those working in the nursing department are fully trained and competent for the job they perform. If she was unaware of the education program of her employees, she should never have come to a meeting to argue against educating her staff.

 Corporate Responsibility

Some of our research team felt the nursing department was not only deceptive, but also engaged in a cover-up for three years to prevent their problems from being exposed. How could employees’ performance be improved when the vice president of nursing refused to admit to the problems within her department? Is this arrogance of power, territorial defenses, or just ignorance? Perhaps she was busy blaming the lab for all her department’s problems and was unable to see the real issues.

Today, at a time when corporate responsibility is a very critical issue in business operation, it is shocking to uncover such a lack of integrity from a hospital department. For many years now, JCAHO has been trying to encourage hospital CEOs and administrative officials to take leadership on quality improvement to save patient lives. How can this be accomplished when a whole department finds it difficult to admit to both training and performance problems? Such a revelation is very disappointing indeed. The nursing department is not willing to solve this problem to prevent more patients from dying because they are too deep into denial and cannot see straight! What a crying shame! Although we are dealing with lab-nursing problems, such inter-departmental problems are not unique to these departments alone. There are problems between nurses and pharmacists, physicians and laboratory, nurses and physicians, etc. leading to many medical errors. Hospital administrations should create bargaining tables to address all these problems to help reduce errors and improve the quality of care.

 Solution Intervention and Generalized Problems in Hospital

In this particular lab-nursing committee, the group should be dismantled and reorganized as was previously advised by the network CEO early this year. The vice president of nursing and her contact person should not be included in the new committee. However, other nursing representatives should be picked from the nursing department, including the hospital’s quality improvement director and those who are ready to work with the lab to fix the problems instead of those playing the game of deception. At the August lab-nursing meeting the lab representatives were given many hints that the nursing department was working on other committees to address the specimen collection problems. They were planning to end the lab-nursing committee. What a nice way to shoot the messenger because the news is bad? The lab-nursing committee was designed to address the problems between the lab and the nursing department. It was not designed to address the problem of specimen collection alone. So, they could no longer take the heat and were ready to get out of the kitchen!

 In another hospital within our research group from another state, the hospital attorney refused to respond to complaints from employees regarding some systemic problems within the hospital. One of the frustrated employees reported the case anonymously to the hospital quality improvement committee. When the hospital attorney realized he was exposed, he shut down the anonymously reporting system to cover his errors. Both physicians who were on the quality improvement team got very angry, they not only left their positions at the hospital, and one of them called JCAHO to file a complaint.

 Many of the positive initiatives could have worked to reduce medical errors if not because of resistance to change, professional arrogance, and territorial defenses observed throughout this study. Many of the health care professionals hate change, even if meant for the good of the patients. The saddest part is the “I don’t care attitude” seen with some hospital administrators regarding the need to improve the quality of care. Like one frustrated nurse said before she quit her job, “People on the outside will not be able to imagine the giant problems being confronted by health care workers everyday because of the screwed up systems in place and lack of interest to change.” The Joint Commission of Accreditation of Healthcare Organization should hold both the hospital CEOs and the medical staff directors responsible for quality improvement initiatives throughout the hospitals and other health care facilities. If they do not respond, the commission should have the right to pull the accreditation of such health care institutions. This is the time for JCAHO to act immediately to protect the public from harm.

 Report by ‘Yinka Vidal