unmet expectations: when patient safety takes a back seat
TRANSCRIPT
iI recently read an essay in Nursing for Women’s
Health (Stichler, 2007) about the birth of twins
from the perspective of the family. The au-
thor—a nurse as well as the twins’ grandmoth-
er—closed the article with this statement: “I
am grateful for nurses who are called to touch
our lives and heal our hearts. I am proud to be
a nurse!” I, too, am the grandmother of twins
who arrived after much hopefulness and failed
attempts at pregnancy. As a clinician, my heart
identifi es with the author’s refl ection on nurses
who touch our lives.
It was ironic that I read this essay at the
same time I was contemplating how to record
my own family experience. My daughter-in-law,
Ginger, was a 29-year-old primigravida. She
entered the hospital for an elective cesarean
section at 37 weeks’ gestation after a pregnancy
that had been basically unremarkable. On the
day of delivery, Whitney and Weston arrived,
weighing 5lb 3oz and 5lb 4oz, respectively. I
watched as my son, Matt, readily took on the
role of “Daddy.” He exuded a confi dence and
calmness that defi ned his strength and char-
acter. He reported to us that the babies were
perfect, crying vigorously, pink and had
Apgar scores of 9/9.
Our family, Ginger’s family and several
friends eagerly waited for a summons to meet
My anxiety started
to bubble up
and an alarm of
uncertainty began
to sound in my
head.
88 © 2008, AWHONN http://nwh.awhonn.org
(continued on p. 86)
Marcia Hodges, MSN, RNC
Expectations Unmet
When Patient Safety Takes a Back Seat
Marcia Hodges, MSN,
RNC, is a clinical special-
ist in perinatal sales at
GE Healthcare in Jacksons
Gap, AL.
Address correspondence to:
DOI: 10.1111/j.1751-486X.2007.00282.x
the new babies. I explained to them that the fi rst
hour of recovery was a very important time to
assess the mother and we shouldn’t even expect
to see them for at least an hour.
Two hours later, Matt met with the anxious
family members to update us. He remarked that
Ginger was very sleepy and he had promised
her that she would be able to have time with
her babies alone prior to any family members
or visitors being admitted to the room, and he
wanted to honor that promise. Ginger hadn’t
been able to sleep well over the past several
weeks, and we could certainly understand her
need to “catch up” now that she was more than
10 lbs. lighter and without the activity of two
fetuses inside her. Matt was animated as he
described the babies to us; Whitney looked like
Ginger, and Weston like him. He said they were
bald and small but perfect and quietly sleep-
ing under the warmers. We couldn’t wait to see
them, but we would.
Another hour passed and we still weren’t in-
vited to the room. My anxiety started to bubble
up and an alarm of uncertainty began to sound
in my head. I’ve recovered many patients over
the years and this seemed to be an extended
period of recovery, even for a patient who was
sleepy and had delivered multiples.
After four and a half hours, I couldn’t take
it any longer. I walked down to Ginger’s room
with the entourage in tow and knocked on the
door. My son met me at the door and let us in
and proudly took everyone over to the warm-
ers. I glanced at the infants and wanted to join
the inspection, but I became overwhelmed with
fear when I looked at Ginger. I walked over to
the side of her bed and saw that she was lying
with her head fl at and her color was very pale.
In fact, she was almost the same hue as the
white sheet underneath her. When I tried to talk
to her, she didn’t respond but only fl uttered her
eyelids as if she couldn’t open them. I glanced at
her blood pressure monitor and saw a read-
ing of 80/40. There was no urine output in her
catheter bag and her skin was cool to the touch.
What happened next is that I became that
irrational family member that I’d encountered
in my experience as a nurse and a manager, but
I felt justifi ed. I noticed that the hospital bed-
side monitoring system provided the ability for
the nurse to document medications and view
the fetal monitor strip while the patient was
in labor, but the nursing documentation was
completed in a paper chart that was positioned
outside the room on a wall chart. Because the
nurse was outside the room charting, I asked
her to come to the bedside and said, “What’s
going on here? Ginger is unresponsive with no
urine output and is pale and hypotensive! Has
anyone checked her bleeding or her hematocrit
or notifi ed the physician?”
The nurse didn’t appear very impressed with
my assessments but stated, “She’s been very
sleepy.”
I continued, “This is more than very sleepy.
This is a patient who’s lost too much blood and
may still be hemorrhaging.”
The nurse then asked all of us to leave
the room. We complied, but I didn’t leave the
nurse’s desk, even though I could tell by the
busyness and the lack of eye contact with me
that I wasn’t a welcome guest.
Thirty minutes later, the nurse approached
me and said, “We’ve given Ginger Hespan, we
now have two units of blood infusing, we have a
physician at the bedside and we are concerned.”
“I’m very glad to see concern!” I replied.
Ginger slowly started to recover but didn’t
have the strength to sit up or even hold her
infants until the next day. There were many
apologies from nurses and the physician, but
no one gave a satisfactory answer as to why it
took a visitor to illicit immediate care or if there
was any concern to her condition prior to this.
Ginger’s hematocrit the next morning was 19.
I’ve tried to refl ect on this situation with an
open mind, coupled with my years of experi-
ence. The unit wasn’t extremely busy the day of
this delivery and the nurse assigned to Ginger
didn’t have any additional patients to care for.
I do know that this situation would never have
progressed for this length of time at my smaller
regional hospital. After one hour of recovery
following a cesarean section, the physician
would have been notifi ed if the patient didn’t
meet certain recovery care standards.
I was left with several questions. Did the
nurse adequately assess her patient? Did she
meet competency requirements to care for her
patient? Was the physician notifi ed prior to the
questioning by the family? Was the nurse fo-
cused on meeting her documentation require-
ments and tasks and, therefore, did she fail to
actually be aware of what was occurring with
Did the nurse
adequately assess
her patient?
Did she meet
competency
requirements
to care for her
patient?
86 Nursing for Women’s Health Volume 12 Issue 1
(continued from p. 88)
her patient? What could be the root causes of
this unacceptable outcome?
One thing I identifi ed in this scenario was
that the nurse had to leave the room to chart
due to two separate charting systems. Technol-
ogy has changed our way of practicing and has
actually allowed us as clinicians to be more ef-
fi cient. It can assist us to provide complete, con-
sistent care, but it mustn’t drive our practices.
For instance, if the nurse could have completed
her nursing documentation in the room while
at the bedside, perhaps this would have assisted
her in really “seeing” the patient and providing
timely interventions. Are some of our hospital
practices or the fear of litigation or our dispa-
rate systems prompting nurses to spend time
documenting, many times in multiple places
and taking them away from the bedside?
The second thing I learned from this experi-
ence is that I have a responsibility as a profes-
sional to request a meeting with the director of
this unit and express my concerns in a non-
judgmental manner. How can I hold the nurse,
physician or hospital accountable if they’re not
aware of my disappointment in this experience?
If I truly value patient safety, I must present the
facts as I see them and respect the fact that no
nurse, physician or manager would ever want
to provide fractured, suboptimal care for their
patients. That’s what we’re all about. Evaluat-
ing near misses and root causes of less than
optimal care will only help us identify those
areas and interventions that will truly bring us
to improved outcomes.
There’s always a feeling of regret when
medical outcomes don’t meet our expectations.
I felt this as a nurse manager when I had to
review cases in my own unit, but I experienced
the disappointment at a deeper, more personal
level when my own family was involved. Many
times these situations illicit anger, lawsuits and
fi nger-pointing. My professional experience has
led me to believe that most unwanted outcomes
are process related. I don’t know of one nurse or
physician who approaches his or her work with
the idea of creating harm or providing inad-
equate care due to lack of concern or unprofes-
sional behavior.
I agree with the author of the previously
mentioned article. I, too, am proud to be a
nurse and I want to take every opportunity
to do my part to help nurses of today meet
head-on the challenges they have and to help
identify risks that could affect perinatal patient
safety. By doing so, I hope to help them fi nd
fulfi llment in being the best nurses they
can be. NWH
ReferenceStichler, J. F. (2007). When birth is not as planned:
Joy and fear interwoven. Nursing for Women’s Health, 11, 217–220.
February | March 2008 Nursing for Women’s Health 87
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Evaluating near
misses and root
causes of less
than optimal care
will only help us
identify those areas
and interventions
that will truly bring
us to improved
outcomes.