The Nurse

 

Any Nurse USA

I rarely, if ever comment on a medical injury case (an injury or death that is caused by the care received through the healthcare system).  I understand that people who work in healthcare are human, and mistakes are made.  I also understand the pain and suffering that goes along with the injury or loss of losing someone to the same people you trust to help.  But this case is getting so much attention, I would like to throw my two cents in for what its worth; recognizing I too, do not know the whole story.

Here is a short version of the story  https://www.youtube.com/watch?v=CP3sSB4lf3Q

This past year we have hailed healthcare workers as heroes for the care of people with the deadly virus and many leaving their own families to care for the loved ones of strangers.  Now, this breaking news of a situation that happened even before the pandemic, is coming to light. 

A nurse overrides all the safety measures in place to give a patient the wrong medication.  When the nurse gives the patient the wrong medication, the patient dies.  The nurse admits her mistake, is fired, loses her license, and is treated as a criminal and now, convicted of a crime, criminal negligent homicide.   She will be put in jail as are those convicted of crimes.

In my humble opinion, putting her in prison makes no sense.  She made a mistake; she admitted her mistake and the patient can’t come back.  Treating her as a criminal helps no one.  The patient’s family wanted justice and are entitled to something.  There may have been a financial payout, I hope they get some counseling, but is this nurse a criminal? When did the laws go into effect that a medical professional with no criminal history, has committed a crime by making a mistake?  Do they teach in nursing school that if a nurse is distracted, makes a mistake, and injures or kills someone they may be convicted of a crime and serve prison time?

We know that driving over the speed limit, texting while driving, drinking and driving are all wrong and can cause the death of someone, but who isn’t guilty of at least one of these things?   Its only when someone gets caught is there punishment and yes, they can be treated as a criminal if someone is killed during any of these dangerous acts while driving.

For the past twenty-five years  with Pulse Center for Patient Safety Education & Advocacy we have been teaching the public to be more prepared as a patient but there are things, like this incident that we can never teach people to prepare for.  There must be a certain amount of trust in the people who work in the system to care for us and our families.   So, what happened in horrible, but I question it being a crime.  It would be interesting to know how many nurses are willing to admit that they too have bypassed systems and why.  How many times the problem has been reported and ignored.

How much better it would be for this nurse to be an educator for other nurses since this case will probably go away quietly and in a few years it will happen again. Instead of ten years in jail, ten years of educating others. How many nurses across the nation have done the same thing, reported a problem and felt ignored?  Do they become a “whistleblower” or keep quiet for fear of losing their job?

The family needs to come out and talk about their pain, what it was like to lose a loved one this way.  Put a face on the medical mistake, but not in the court room.  Cases like this need to be talked about so others can learn.  I’m sure in a few years we will hear of another case, and another and many we won’t hear about because the media won’t pick them up.

There is no secret that healthcare workers often don’t follow the “rules”.  One way to easily know this is just by watching the lack of handwashing.  I am very conscious of handwashing because its is one of the simplest ways to know if a healthcare worker will follow policies and with lack of hand hygiene, I’m sure there are many other opportunities to cut corners, some are just more deadly than others.

  

 

2021

Each year, in the United States alone, 7,000 to 9,000 people die as a result of a medication error. https://www.ncbi.nlm.nih.gov/books/NBK519065/

  

2021

Parents say Walgreens mistakenly injected them and their two kids with the Covid-19 vaccine instead of flu shot

https://www.cnn.com/2021/10/13/us/parents-say-walgreens-mistake-covid-vaccine/index.html

 

2014

Hospital medication error kills patient in Oregon https://www.cbsnews.com/news/oregon-hospital-medication-error-kills-patient/

 

2011

Devastated nurse committed suicide after she accidentally gave baby fatal overdose https://www.dailymail.co.uk/news/article-2008789/Nurse-committed-suicide-medical-blunder-led-death-baby-overdosed.html  

March 14th Isn't Just Another Day

March 14th; Why it Matters

March 14^th isn’t just another day for me.  Many people have anniversaries and birthdays worth remembering or celebrating. March 14^th is a day I allow myself to feel sorry for myself.  But, as I have learned over the years, it is often the build up to that day that causes more anxiety, sadness or upset than the day itself.  Allowing myself time to be angry, depressed, or sad - with a limit, has been helpful to me.  I encourage other people to do that too instead of feeling guilty, for being sad or angry. 

Fighting our sadness or anger can cause buildup and resentment.  Allowing it to happen, without guilt or shame can be healthy and then thinking about being finished with negative feelings can bring us back to our old selves and be “done” and move on.

March 14^th is one of those days for me that I always regret coming around.  It was many, many years ago, but the words said, and almost every movement I made is implanted in my brain.  This is believed to be because of the adrenaline that happens with sudden emotions.  

I was escorted into a room by the emergency room staff and behind closed doors I sat for what felt like hours.  Each time the doctor would come in and tell me they are working on him; I would suggest she leave and go back to caring for my son.  It didn’t occur to me that there was a team caring for him and she was the one sent to keep me updated.  Until finally, she came back and said there was “nothing else we could do”.  My son was dead.  It took a while to sink in and though I remember the gasps I heard from the people I love with me; it took me a long time to cry.  I had to see him, decide to donate what organs could be saved, and plan for – what now – there was no one to tell me what to do. 

As the days and months moved on, I had to figure out how a little boy, who had chronic ear infections, would get his tonsils removed and bleed for 8 days – bleed to death, and a body filled with infection went ignored by all the doctors I saw during that week.  Each of the 5 times in the week leading up to his death, I was in a different emergency room, everyone said he was fine. 

I sat numb in the weeks that followed his death thinking that I was right, and all those doctors were wrong.  To prove I was right, it cost my son his life.  I wondered why, in all the months that followed, no one asked me what went wrong.  What did they miss?  Would anyone learn?

If Michael survived because of what I know now, and I spoke up louder, insisted more that something was wrong, insisted that they bring him back to surgery and any one of the 5 doctors I took him to in that week saved him, there would be nothing to learn.  It would be how it’s supposed to be.  He would get better, and we would all go on with our lives.  We do not count the people who survive or prevent medical errors by speaking up.  Only the dead are counted and that often doesn’t work either.  Medical mistake was not on his death certificate.

As the years moved on, I committed myself to encouraging people to speak up for themselves or their loved ones. I began attending medical conferences in 1999 so I could hear the medical professionals talk to each other about safe patient care, medical errors, and injuries, caused by their mistakes or systems that failed them and us, the patient, and families. 

I will never forget the phone call of a woman who said her child was going in for a tonsillectomy.  She was nervous but wanted to ask me what she should know before taking her child for surgery.  Would I mind giving her advice.  It was when I realized that we could save lives by talking to each. What we, the people who live these tragedies can be doing.

When families experience an injury or a death caused by the healthcare system, it is hard to “blame” because we often don’t have the facts and there is no report written up as there is in a car accident.  Medical care is often as complex as driving with no driver training.  We must completely count on the expertise of the others on the road. 

Over the years I like to think of my activism turned advocate as a good thing.  I would like to think that in the 25 years with a nonprofit organization Pulse Center for Patient Safety Education & Advocacy based on educating the public, encourage the sharing of information and helping people learn to advocate for themselves and their loved ones, we are in a way the driver’s education we all know, and respect meant to help, support, and save lives. 

This week, the second week of March is Patient Safety Awareness Week on its 20^th year - The IHI knows of the importance and many hospitals celebrate patient safety as well as healthcare quality organizations such as The Joint Commission.  Some even use this time to honor those lives lost, but still., you won’t find it on any calendar of awareness though I have tried for years to get it recognized. Awareness Months, Appreciation Weeks, National Days for Marketing | Crestline

So as March 14^th comes and goes quietly for me, I can only hope that someone will speak up, speak out and another life will be saved.