Patient safety lessons from Starbuck's

Anyone who knows me, would agree that saying I like coffee is an understatement. In fact, coffee is truly one of my life's pleasures. Right up there with anything chocolate and the beach. A good cup-a-joe, anytime of the day - hot or iced, frappuccino or espresso, I'm guaranteed to love it.

So what does my love of coffee, Starbuck's and healthcare have in common? Probably very little at first glance; besides the fact that coffee is the fuel of healthcare providers and clinicians everywhere...we may be able to learn something from the highly rated java-giants.

A typical shift day for me begins with a trip to the local Starbuck's for my usual special latte for one last jolt of caffeine to get through my unpredictable day. No matter what time I visit, I am always greeted by a friendly voice in the drive-thru that identifies themselves first and says something like "Good morning or welcome, my name is so-and-so, how may I help you today?" WOW! It always impresses me...really. Every day. All the time. No matter the person taking my order. I respond the same...."Good Morning! (It's contagious you know) I'll have...I won't bore you with my special coffee needs" And here's the best part...wait for it.....the friendly barista READs BACK & VERIFIES my ORDER! (RBVO) Ta-Da! Yes, they verify what they heard you say. Amazing. And if it is wrong they correct it on the spot and you get the wrong drink in addition to the corrected order. Now granted, no one is going to die or be injured with the wrong coffee-drink, but that is not the point.

In our clinical practice settings we give and receive orders or diagnostic results or other patient-related communication all the time and it is extremely easy to misinterpret or transcribe them incorrectly. The difference is, we can't take back the wrong treatment, medication or diagnostic result and it can most definitely harm the patient. I give telephones quite frequently and I am surprised at how many times they are not read back & verified. I often ask them to repeat the order back to me or I repeat it myself.

If Starbuck's thinks it is important enough to Read, Back & Verify your Order (RBVO) shouldn't it be important enough to us where the stakes are much higher? Incidentally, those of use that work in the acute care (hospital setting) know that CMS and The Joint Commission already think so...this was a National Patient Safety Goal for many years; it is now part of the Provision of Care Standards and yes a hospital can actually be penalized for not demonstrating evidence that a verbal or telephone order was RBV.

Startbuck's greets their customers with kindness and reads back their orders to maintain a high level of customer service and satisfaction, not because people will die. Clinicians and providers at every level should make reading back and verifying communications a natural part of their practice and a priority for patient safety.

Hard pill to swallow???

For many Americans sweet dreams are not obtainable. They complain of poor sleep everyday - or more appropriately every night. The elderly are much more likely to report sleep problems. Due to a myriad of reasons, most physiologic sleep is altered and they find themselves up at night when they should be getting restorative sleep. For that reason the use of sleep aids has increased...and so have the consequences. Many drugs leave patients with 'hangover' effects impairing judgment and physical mobility long into the daylight hours after taking these prescription sleep aids - especially long-acting formulas. For the elderly this can be especially dangerous leading to increased risk for severe injuries related to falls, mismanagement of medications and other accidents. Some hospitals have reduced the use of such medications in hopes of reducing confusion, falls and other sequelae (especially in the elderly). In the hospital setting, patients often do not recover from untoward events. 

Cascade Iatrogenesis is a series of adverse events triggered by an initial medical or nursing intervention initiating a cascade of decline. It often results in a poor outcomes for the patient or inability to return to pre-illness level of functioning and is preventable. Many of these events are precipitated by medications - either a new medication, too many medications (polypharmacy) drug-drug interactions, over-sedation, so on and so on...
As for the use of sleep aids, especially in the acute care setting, it cannot be overstated - we must be vigilant and cautious when utilizing these or any medications in the elderly patient. Having an a lower dose option may be helpful, however we should really be considering alternatives rather than adding one more pill to the the medication soup

See the following:
Wall Street Journal: Citing Dangers, FDA Requires Lower Doses for Certain Insomnia Drugs http://online.wsj.com/article/SB10001424127887324081704578233652166139618.html?mod=dist_smartbrief 
National Sleep Foundation: http://www.sleepfoundation.org/article/sleep-related-problems/sleep-aids-and-insomnia

Pearls for Practice: Newborn Assessment

What do you know about cyanosis of the hands and feet of the normal newborn?

Another great episode of Insights in Nursing!

Great discussion on the future of nursing, how staffing patterns impact patient outcomes and mobile technology in patient care!

http://insightsinnursing.com/2012/08/happy-nurses-equal-happy-patients/

Enjoy!

History taking getting too personal?

Whether or not you support the constitutional right to bear arms and what you believe the right to free speech covers, there is a definitely a controversy brewing in Florida over the "Gag Law."  A recent ruling states that Florida "cannot enforce a law that prohibits physicians from asking patients whether they own a gun because it infringes on their First Amendment right to free speech." The National Rifle 

Association (NRA) helped lobby for the law believing the second amendment was at risk and stating that the information obtained by healthcare providers would go into individuals' permanent health records. Physician groups argue they are trying to protect children and that assessing whether there is a gun in the home is necessary to provide education on gun safety, similar to bike and car safety. Other groups disagree. But what about adult patients? 

The question then becomes what information is necessary for healthcare providers? How is some of this and other social information used in relation to patients' overall health care? Some argue that some information should not be kept in their permanent medical record and do not understand the relevance. 

Would it be appropriate to assess a person with profound depression risk for suicide? Part of that assessment would include assessing for a plan, access to methods and ability to carry it out.  How about a patient that has substance abuse issues - is it appropriate to ask about the use of drugs and alcohol? Sexual orientation, partners? You get the point...

As an ACNP I understand the concept of history taking but I also understand the need for being respectful of sensitive information. Of course many patient's do not share everything with healthcare providers out of fear, or stereotyping or some sort of recourse. Will this situation in Florida have the effect they are looking for - preventing unintentional firearm accidents? I'm not sure. But I do know that constitutional rights are polarizing topics and it seems that most sit on one side or the other. Regardless of your personal beliefs on firearms or free speech, when it comes to caring for patients, the patient must remain central in order to be a true advocate.

Florida 'Gag Law' on Physician Gun Queries Blocked for Good

Roundup: Doctors entitled to free speech, too

Taking care of everyone but ourselves

It is no secret that a majority of Americans are overweight. Some studies predict that 42% of Americans will be obese by 2030; with obesity defined as weight greater than over 20 - 25% of normal body weight. The most common health consequences of obesity are also well know - hypertension and diabetes. What many lay-persons may not be aware of are the myriad of other health issues that result from obesity: cardiovascular diseases (risk of cardioembolic events such as stroke and myocardial infarction) renal dysfunction, infertility, erectile dysfunction, obstructive sleep apnea, risk of developing various cancers, not to mention decreased quality of life (this list is by no means exhaustive).

Nurses, physicians, respiratory therapists, paramedics and others, on the other hand are all aware of the consequences of poor health such as obesity and chronic hypertension. Yet, there are many healthcare providers and workers that are in extremely poor health, smoke, are very obese. How many of us work with colleagues that can not respond to code situations quickly and you find you are the only that can actually run to the bedside? Everyday tasks are fraught with shortness of breath, fatigue, painful joints and other ailments during the long 12-hour shifts or longer. Add to that lack of sleep and stress of the shift (see Burning Out: Combating compassion fatigue & moral distress) and nurses and other care providers are set up for health problems. Unfortunately, nurses are not necessarily good at caring for themselves on daily basis. I am talking daily renewal and refreshing your body and mind - taking time to clear your head and let go of the stress of the shift. Celebrate the saves and mourn the losses. When it comes to preventive health and wellness, we tend to care for those around us and put ourselves last; waiting to the last minute or too long to seek care. But I regress....

If you walked into my old unit almost any day of the week, you would find some sort of processed, junk food in the lounge. I myself have an insatiable sweet-tooth and am known for always having a chocolate stash! But I am also not obese, not even overweight - not even close. I am a vegetarian and I rarely sit still and I drive my family crazy about being healthy because I don't want any of us to suffer from the diseases I treat patients for. My point is this...you never see a plate of veggies and fruit in the nursing unit lounges. When was the last time you saw a big bowl of hummus and cucumbers? You may see salsa, but with corn chips and out of jar! Cookies, brownies, candy, chips and more. Even the cafeterias struggle to cook healthy options. And firehouses...they definitely like their bacon and sausage in the morning and meat and potatoes in the evening! (No disrespect to all my paramedic and firefighter friends!)

On a serious note, it disturbs me that we as educated professionals are teaching and preaching to patients and their families how to stay healthy and prevent further admissions by "reducing dietary sodium," "smoking cessation," "cutting back on alcohol consumption," "increasing fruits and vegetables while reducing sweets and fats," yet the collective we is just as unhealthy as they are. What message are we sending our patients? One news media article cited that 55% of nurses are obese. It is clear we are not following our own advice. Again, what does that do to our credibility? How can we take better care of ourselves and be better role models for our patients?

With healthcare at the forefront of discussion in the media and a focus on prevention and reducing costs, it is important that we are do our part to care for ourselves and each other.

I encourage you go to the Nurses Health Study link. The partners have been studying the health of nurses since 1976 and currently recruiting nurses for their third study.

The Nurses Health Study

Burning out: Combating compassion fatigue & moral distress

Most of know that feeling as being "burned out." When you fell like you cannot do your job another shift let alone the rest of your working days. The irony is that we became healthcare providers (nurses, medics, physicians, etc) because we wanted to care for others. To make a difference. We knew our work was that of service and that some days it would be hard. And although television often portrays healthcare as glamorous and adrenaline-producing every moment of every day, we know the real truth.

Compassion fatigue is defined as a loss of compassion and caring over time. It is a condition that is hallmarked by emotional, physical and spiritual exhaustion that occurs from caring for and internalizing the suffering of others. Compassion fatigue is also referred to as secondary post-traumatic stress disorder. Nurses have a propensity to carry on the burdens and problems of others - their patients, coworkers, families, and friends which may leave them exhausted and feeling empty. (I recommend reading Bertice Berry's Blog, especially Day 145: Seeing Miracles)

Moral distress is another term often used related to burn out, however often there is an ethical component or dilemma associated. Nurses frequently find themselves in the middle of conflicts involving patient care issues, especially related to end-of-life or futility of care. This produces a great deal of stress for the nurse whom often has no outlet.   

We have all seen it - burned out coworkers call out more, are late to work, have no interest in most of what they do, chronic fatigue, decreased productivity, high turnover, workplace injuries, reduced satisfaction in work and home, and even more patient complaints. Not to mention patient safety events; if our head is not in the game so to speak how can we be sure we are not going to make a serious error or failure to rescue or prevent harm to a patient.

There are many reasons that nurses become burned out with their jobs. High patient acuity, staffing issues, conflicting values and expectations for time between work and other life responsibilities and difficult or devastating patient situations.We talk about it. We say, "Oh, I'm so burned out, I just don't care anymore." Yet we do little to nothing about it. At work we barely support each other; often because we are so busy ourselves and consumed with our own tasks and crises. Helping and supporting each other through difficult situations and even the everyday ones has to be a priority. It is wearing us out and creating an undercurrent of distress and hostility and resentment. Having formal systems in place to help us deal with difficult emotions is important not only for the staff member involved but all other staff, and more importantly for the patient. 

At home we do even less. We set no priorities of care for ourselves. Do not allow ourselves to grieve a loss at work or at home. We do not give ourselves permission to really care for ourselves in a healthy way - sleep and eat well, exercise, rest and relax, read a good book, play and so on.

I have posted some very good resources on moral distress, compassion fatigue and burn out. I strongly encourage you to read them and develop resources in your workplace to combat this insidious foe to our job satisfaction and personal happiness.

Addressing Moral Distress: An Important Step toward a Healthy Work Environment

Six Ways to Deal With Compassion Fatigue and Burnout, Kendra Mims, ENA Connection (Mar 2012)

How do I deal with compassion fatigue?

6 Ways Nurses Can Beat Compassion Fatigue