By October 10, 2009 2 Comments Read More →

RN Doesn’t Follow Standardized Work, Exposes Patients to Risk of Disease

Broward General nurse possibly exposed patients to risk – South Florida – MiamiHerald.com

Story and nurse discussion here

A number of you (thanks!) sent me this article from CNN about a Fort Lauderdale nurse who resigned — and may face criminal charges — for reusing disposable IV bags and chemical stress test supplies, thereby exposing patients to risk of hepatitis or HIV.

Terrible.

She was turned in by a co-worker who saw her violating the standard process:

Hospital managers learned of the problem when someone reported seeing the nurse using the same saline bag and tubing more than once when giving intravenous fluids to patients undergoing chemical cardiac stress tests.

The good thing is that somebody noticed that she wasn’t following the standardized work, although it wasn’t a direct supervisor or manager. The nurse certainly needs to be held accountable, but what about managers? Can managers be held responsible for what seems like an individual violation of rules? Back to the Wachter discussion from last week, what’s the balance between a systems view (“no blame”) versus accountability?

It’s unclear if this was a one-time problem or if it was this was the individual nurse’s standard practice:

The hospital did not offer an explanation on how an employee could have continued a dangerous practice for five years without being noticed or admonished.

It’s unclear how there would be proof of this — is it really a 5-year track record of continued risk and bad practice? It’s prudent to assume the worst and test every patient who was under her care.

Assuming it WAS going on that way, every day, for five years — why didn’t managers notice? Managers and hospital leaders can’t hound employees every single minute, nor should they.

Rather than just pressing charges against the nurse, Qui Lan, I’d also ask these questions:

  • What was the training process when she was new to the hospital? Yes, she was a qualified nurse, but was there training done about how that hospital does chemical stress tests?
  • Were the correct supplies easy to get and always properly stocked?
  • Did the nurse (and other nurses) have enough time to do their work properly?
  • Did managers or supervisors ever verify that she (and other nurses) were following proper procedures?
  • Was this just a single nurse who was cutting corners, or was this a wider problem?
  • What other corrective action has been taken, other than accepting the nurse’s resignation?

The hospital CEO said:

“This is an individual’s unacceptable practice that once discovered was immediately corrected,” said James Thaw, CEO of Broward General Medical Center, in a written statement.

Let’s certainly hope it was just one individual.

Lan’s attorney says:

“Ms. Qui Lan has been a registered nurse for over 37 years providing excellent medical care to all of her patients. She has an excellent reputation in the medical community due to her professionalism and ethical manner. We are confident that once the facts surrounding this incident are revealed, Ms. Qui Lan will continue to be seen in the same light.”

Is this just “create some doubt” lawyer talk, is there more of a systemic problem behind this story? It will be interesting to follow this and see what comes out.

If you’re a leader at another hospital, do you read this and then take steps to verify that the same thing isn’t happening with one of your nurses, as hard as it might be to believe that it could happen where you are?


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

2 Comments on "RN Doesn’t Follow Standardized Work, Exposes Patients to Risk of Disease"

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  1. Andrew says:

    Mark, I think the explanation lies in the fact that it occured in Broward :) This is not the first process issue that has occured in that area of the US…………

    Andrew

  2. Raven Morgan says:

    A dear friend of mine is one of the patients Qui Lan reused tubing on – she should be charged criminally for assault and lose her nursing license! As of today, the police have done a criminal investigation and feel she “has done no harm”, so there will be no criminal charge. The Florida Board of Nursing has allowed her to still have an active license with no disciplinary action taken, not even a board of nursing hearing is pending in this matter. I hope the nurse and the hospital get hit with a huge lawsuit!!!

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