Toxic Hierarchy and Patient Safety

So when are we going to stop using the old IOM figure of 98,ooo people dying a year from preventable errors and start using more correct data.  As Propublica recently reported, the figure is more like 210,000 to 440,000.  That makes total sense, since HHS’s 2010 study reported that 180,000 Medicare recipients die every year and not everyone who dies from a medical mistake is on Medicare, as Lewis Blackman, Rory Staunton, and Michael Skolnick’s parents know all too well.

One of the biggest factors in patient deaths and injuries is the punitive, unsupportive, and toxically hierarchical medical system that has developed over centuries.  Whether they are  nurses, physicians, or other healthcare professionals or workers, people are terrified to admit that they have made mistakes or need help.  Physicians and nurses and others are socialized not to admit that they don’t know something and need help.  When I was recently presenting our play Bedside Manners at a large teaching hospital, a nursing student told a typical story in the workshop following the performance.  First she explained that no one in the teaching hospital where she was doing a clinical rotation ever even acknowledged her presence, much less said hello.  Physicians, she said, looked through her as if she was invisible.  Most nurses regarded her as a nuisance.  So much for a good introduction to the “team.”  “We are made to feel unwelcome, as if we are a problem.”  Then she recounting the following story that says volumes about the problems of patient safety encountered everyday in both in and outpatient settings.

This young woman said she was observing an attending GI physician performing a colonoscopy with a resident.  The attending asked the resident to do a math calculation in his head.  The nursing student said, the resident just froze and couldn’t do the calculation.  The attending turned to the nursing student and asked her if she could do it.  She knew she could but thought, “oh this is just going to be terrible for the resident.”  Nonetheless, she did the calculation and told the attending.  Sure enough the attending turned on the resident and used her calculation to ream him out.  “See,” the attending said snidely,” this nursing student (as in just a lowly nursing student) could do this and you couldn’t!!)  The nursing student was appalled.  Not only because of the way the attending turned what should have been a teaching experience into a shaming experience, but also because of what he felt about nurses.

There is so much that is wrong with this story that one could spend literally an hour debriefing it.  It’s sexist, anti-nurse, anti-team, terrible pedagogy, just the kind of shame and blame that should be avoided.  But upon hearing this, my first thought was, will this resident ever, in his career, admit that he doesn’t know something if this kind of physician is his role model?  I doubt it. If patients are to be safe we have to do more than insert IVs correctly, and wash our hands.  As Lucian Leape has pointed out, we have to put respect into the system and reprogram our brains to never ever humiliate anyone like this ever no matter how angry or frustrated people are.  I’ve made up some cards because of experiences like this.

Team Work Never Events

•  Never refuse to help a fellow team member
• Never refuse to come to the bedside to assess a patient
• Never fail to share necessary information
• Never disrespect anyone you work with
• Never deny you did something when you did it
• Never…

Teamwork Always Events

• Always make introductions (first and last name, and role)
• Always clarify roles
• Always share/solicit information
• Always give and expect feedback
• Always confirm that roles & plan of action are understood
•  Always repeat crucial information