Talking About Breaches of Ebola Protocol is NOT “Blaming Nurses”


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As I've written about (here and here) poor systems, a lack of protocols, and not adhering to protocols and standard practices are almost always “system problems.” A lack of proper training about protocols is a system problem.

System problems are the responsibility of hospital management, plain and simple.

National Nurses United is right to call for better planning and better protection of nurses and other caregivers. See their release: “Ebola-RNs Call for Highest Standards for Protective Equipment, including Hazmat Suits and Training.”

However, I think it's a bit of a straw man argument to say that recent news stories about the Dallas nurse, Nina Pham, who contracted Ebola through the treatment of Thomas Eric Duncan is “being blamed” for not following protocols.

I haven't read anything that said the nurse is anything other than a victim. I don't see blaming taking place. Maybe the general public reacts that way (ah, she's a bad nurse and she screwed up), but you can't control people's reactions.

If the nurse wasn't trained properly on Ebola protocols, including how to properly de-gown, she was a victim.

If the nurse was tired at the end of a long shift and wasn't properly supervised in how she worked or de-gowned (to prevent an inadvertent infection caused by touching her face with a dirty glove, as happened in Spain), she was a victim.

I guess the media can re-emphasize the systems component here.

From the NNU release (from what appears to be an unscientific survey):

Current findings show:

  • 76 percent still say their hospital has not communicated to them any policy regarding potential admission of patients infected by Ebola
  • 85 percent say their hospital has not provided education on Ebola with the ability for the nurses to interact and ask questions
  • 37 percent say their hospital has insufficient current supplies of eye protection (face shields or side shields with goggles) for daily use on their unit; 36 percent say there are insufficient supplies of fluid resistant/impermeable gowns in their hospital
  • 39 percent say their hospital does not have plans to equip isolation rooms with plastic covered mattresses and pillows and discard all linens after use; only 8 percent said they were aware their hospital does have such a plan in place

Lack of planning, lack of education, lack of communication — system problems.

Not having enough supplies and not having the right equipment — system problems.

Hospitals need to step up and prepare. It would have been better if this was already happening, but the wake up call has hopefully taken place.

The CDC says existing protocols are sufficient:

Frieden said investigators have yet to determine how Pham was infected. He stood by the protocols — including the use of masks, gloves and other equipment — saying they have proven safe for health care workers for decades.

Yet, officials want to establish an “official Ebola hospital” in each state.

“We'd like to have at least one hospital in every state that does feel they could manage a patient from start to finish.”

Maybe that doesn't speak well to the level of planning, or lack thereof that has already taken place.

Officials seem to be contradicting each other, with some saying things like “most American hospitals can safely treat Ebola” but others say “I don't think every hospital has the facilities or the wherewithal, or for that matter the desire, to care for Ebola patients.” Hmmm. We have to sort this out.

Nebraska Medical Center and Emory Medical Center are two of the existing Ebola centers. Maybe it's no surprise that they have both treated Ebola patients without any reported infections of staff. Do they have better processes and better training? Better supplies and equipment?

As the WSJ reports:

“The people at Emory have been training for, get this, 12 years,” said Trish Perl, a professor of medicine and a senior epidemiologist at Johns Hopkins Health System in Baltimore. “They have teams that are well-formed and well-developed.”

The news stories and recent actions paint a picture, to me, of a lack of planning. You could blame the CDC. You could blame hospital management. But don't blame the nurses and individual caregivers. We need to protect them as they serve and care for others. That's also a key step, it seems, in protecting the public.

What do you see happening (or not happening) in your hospital? Remember, you can post anonymous comments here, if y0u want.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. I think there is a certain amount of personal responsibility required in order for one to achieve self preservation. You can’t have someone there 24/7 to monitor every move you make. You make it sound like no matter how she got it it was the companies fault.

    • If there was a lack of training or a lack of supervision (such as not having a buddy system during a dangerous operation like removing protective clothing that’s potentially contaminated), yeah that’s primarily the hospital’s fault. To blame the individual would show a poor understanding of human factors.

  2. This does NOT surprise me one bit:

    Dallas nurses allege ‘no protocol, no system’ in treatment of Ebola patient

    In normal circumstances, hospitals do a poor job of managing protocols and a poor job of training and supervising people properly.

    The hospital here was apparently caught completely unprepared. Do you blame the CDC? Hospital leadership?

    Deborah Burger of National Nurses United claimed that the nurses were forced to use medical tape to secure openings in their garments, worried that their necks and heads were exposed as they cared for a patient whose symptoms included explosive diarrhea and projectile vomiting.

    Among the other allegations raised by the nurses are that Duncan’s lab samples were allowed to travel through the hospital’s pneumatic tubes, opening the possibility of contaminating the specimen delivery system. The nurses also alleged that hazardous waste was allowed to pile up to the ceiling.

    The statement also claimed that Duncan was initially kept in a non-isolated area of the hospital’s emergency room for several hours before being moved. Patients who were exposed to him were allegedly only kept in isolation for a day before being moved to be with other patients. In the same vein, the nurses claim that they were made to treat other patients while also treating Duncan, and were offered no more than an optional seminar to deal with changing guidelines.

    “There was no advance preparedness on what to do with the patient, there was no protocol, there was no system,” Burger said.

    Even today, Burger said, some hospital staff at the Dallas hospital do not have proper equipment to handle the outbreak.

    “Hospital managers have assured nurses that proper equipment has been ordered but it has not arrived yet,” she said.

    That’s shameful.

    • More from that article:

      When Ebola was suspected but unconfirmed, a doctor wrote “using the disposable shoe covers should also be considered.” At that point, by all protocols, those shoe covers should have been mandatory to prevent anyone from tracking contagious body fluids around the hospital.

      The word “should” is harmful in hospitals. There is no “should” — there is “do” or “not do” (credit Yoda).

      The shoe covers should have been mandatory.

      A few days later, however, entries in the hospital charts suggest that protection was improving.

      “RN entered room in Tyvek suits, triple gloves, triple boots, and respirator cap in place,” wrote a nurse.

      As cited above, “Triple gloving is a violation of CDC protocol and could make things worse.”


  3. Having an Ebola-specialized hospital designated in each state could give a false sense of security. Other hospitals may not have a sense of urgency to prepare themselves and their staff because the patients will just be shipped off to this other place. In fact, there’s a pretty good chance the first health care providers to care for that patient (and be at risk for exposure) won’t be the Ebola-specialized one. When people are that sick, they’re going to go to the closest hospital to them not the specialized one that may be hours away.

    EVERY hospital needs to take steps be prepared, make sure their staff is ready, and have what they need to protect themselves. This includes proper (easily accessible) PPE, training, protocols, and a culture that supports them voicing their concerns with any of it. This country’s health care system is sorely ill-prepared for a disease like this.

  4. I loved the obvious denial of the Texas hospital. The chief clinical officer stated, “I don’t think we have a systematic institutional problem.” How about that river in Egypt?

  5. Comment from a nurse on LinkedIn:

    Amy Mumpower RN: I watched the video of Dr Sanjay Gupta demonstrating how to put on PPE’s according to CDC for working with suspected infected patients and even he during the demonstration contaminated himself removing the PPE’s. It was obvious that even he was not very familiar with the concept of double gloving, that it doesn’t mean putting on two pairs of gloves at the same time. I was taught over 20 years ago how to don PPE’s during the AIDS crisis when we used to not use barriers for anyone not on some kind of ordered isolation. With that being said, it has been 15 to 20 years and the medical field here in the US has become very complacent about infections.

    • Properly using PPE is like any skill. If you don’t use it, you’ll lose it. I’ve gone through many sets of sterile gloves practicing how to put them on and take them off for the rare occasion that I needed to wear them… and that process is far less complicated than what’s needed for a patient on isolation.

      I just hope hospitals actually let their nurses practice this process so it becomes second nature for them before they have to actually use it. I suspect most of them will just offer training videos and posters, though.

  6. As shared by a doctor on Twitter… the evolving standards for Ebola protective clothing. The old standard was deemed insufficient, so it was updated. Maybe it should have been sooner.

    So the THR nurses might have been wearing gear that adhered to standard. They might have violated protocols in how they took dirty gear off.


  7. See a statement from THR denying many of the allegations.

    It’s strange to me that they say:

    In the pursuit of open feedback, Texas Health Dallas has a strict nonretaliation policy. Employees are encouraged to raise issues and concerns via the chain of command. This process is a core tenet of our culture and values. It is documented in our Code of Business Ethics.

    In addition, Texas Health Dallas employees have two mechanisms available to anonymously raise issues about safety concerns or related matters. It is important to note that no Texas Health Dallas employee did so concerning their care of Mr. Duncan or our two co-workers.

    In the NBC interview, Briana claims she talked to a VP (directly in her chain of command, I presume) who did not follow up with her about her questions and concerns.

  8. I still don’t really understand how “breach of protocol” could somehow be interpreted as “the nurse did it intentionally” yet the Texas Nurses Association seems to be clarifying about something I never heard.

    See video:

  9. > I still don’t really understand how “breach of protocol” could somehow be
    > interpreted as “the nurse did it intentionally

    Interpretation depends on logic and psychology. Fear and blame based cultures predispose people to think blame and take things as blame. Even when the words don’t say that people take it that way.

    This is one of the many reasons why the management system is so important. Even the exact same statement is taken very differently by people. A good management system the statement ‘breach of protocol” can by most employees as fine – an indication of yet again seeing a systemic issue and raising it to be dealt with. In a blame based management system it is taken as threatening and maybe even disrespectful.

  10. Here is a great 60 Minutes piece that highlights the nurses and how brave, caring, and compassionate they are:

    The strength and performance of individual nurses was never in doubt, in my mind. The bigger questions, largely untouched on 60 Minutes, are about leadership, communication, and training…


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