Training as a Countermeasure? The “Fix” You Can Finish by Friday.

In 2006, regulators cited a hospital in Madison, Wisconsin for six violations of state and federal rules after a patient died — three federal, three state. They threatened its license and its Medicare contract. The hospital updated its policies and re-educated its nurses, and the citations were withdrawn. Training as a countermeasure “worked,” in the only sense anyone was measuring.

Think about what you'd have to believe for that to be the right remedy.

You'd have to believe the death happened because a nurse didn't know something. And the regulator who accepted the remedy believed it too, or at least agreed to act as though they did.

Here is what happened. Jasmine Gant was sixteen years old and in labor. She had a strep infection and was supposed to receive penicillin through an IV. Instead she received bupivacaine, an epidural anesthetic, into her bloodstream. She had seizures and died within the hour. Her son was delivered by emergency C-section and survived.

The nurse, Julie Thao, had spent years on labor and delivery. The day before, she had worked a sixteen-hour double shift that ended at midnight. She was due back at seven in the morning, so instead of driving home she slept at the hospital. Gant died shortly after noon. Thao was fired, charged with a felony, pled no contest to reduced charges, was sentenced to probation, and had her nursing license suspended. I wrote about this in 2006: Should Nurses Be Jailed for Medical Mistakes? Blame, Systems, and Patient Safety

Afterward, the Institute for Safe Medication Practices said the death might have been avoided if the containers, tubing, and connectors for epidural medications had been “vastly different” from the ones used for IV medications. Earlier that same year, the Joint Commission had issued a bulletin about the risks of tubing misconnections.

So the warning existed. And when the thing the warning described happened, the answer was a class. Well, after blaming and punishing the nurse, that is.

Training as a Countermeasure Has an End Date

It's tempting to read a story like that as evidence that nobody cared. I don't think that's it, and I never have. The people who chose retraining almost certainly believed it would help. They weren't cutting corners or covering themselves. They were doing what they had been taught to do when something goes wrong, which is to make sure everyone knows better next time.

That's what makes it hard to dislodge. The assumption is sincere and it's inherited. They mean well. But, most leaders were never taught that some countermeasures are stronger than others, or that there's a rank order to them at all. They learned, without anyone ever saying it out loud, that mistakes come from people not knowing or not paying attention, and that the response is to tell people again. Nobody sold them the idea. It arrived with the job, unexamined, which is why you find it in every industry and in organizations run by serious people.

Being sincerely wrong doesn't make a countermeasure work. And there's a second reason this one survives.

Training has a property no other countermeasure has. It ends.

You can schedule it and be finished by Friday. You get a sign-in sheet. You can hand that sheet to a regulator, a board, a plaintiff's attorney, or your own boss, and every one of them will accept it as evidence that something was done. It converts an open wound into a closed task, which is exactly what everyone in the building wants at that moment, including the people who are grieving. We trained them. Now, move on.

Now try that with the connector. Changing a connector requires a supplier willing to make a different one, a purchasing decision, a standards body that agrees on the spec, and enough other hospitals to adopt it that the supplier stays in business. It takes years. You cannot show a standards committee to a regulator on Thursday.

The system doesn't reward the countermeasure that works, but takes time. It rewards the countermeasure you can complete, and quickly.

Which means telling leaders to stop reaching for training won't accomplish much. They are responding sensibly to what they're graded on. What has to change is what counts as an effective response to harm.

You Can Prove You Did It. You Cannot Prove It Helped.

Every countermeasure faces two questions. Did we do it? Did it help?

Training answers the first one beautifully and the second one not at all.

Suppose you retrain everyone on Tuesday. A year passes and nobody gives an epidural intravenously. What have you learned? Nearly nothing. The year before the retraining also had no epidural given intravenously. So did the year before that. This might be a very rare event. If you count zero and call it proof that the training worked, you would have counted the same zero the week before Jasmine Gant died and called it proof that everything was fine–and that warnings from the Joint Commission worked..

Maybe the training was excellent. Maybe it was a slide deck read aloud by someone who had never hung an epidural, at the end of a twelve-hour shift, to people who were charting on their phones. The outcome looks identical either way, which is the problem.

And if the training was bad the first time, retraining people on the bad training gets you nowhere. Two times zero is still zero.

What a Retraining Plan Quietly Says

A countermeasure carries a diagnosis inside it. When the countermeasure is training, the diagnosis is that somebody didn't know enough.

Julie Thao knew what bupivacaine was. She knew it doesn't go into a vein. What she had, that morning, was a few hours of sleep in a hospital bed, two bags that looked alike, and a frightened teenager she had pulled the epidural bag out of the locker to reassure. She told an investigator that she allowed priority for compassion to override the need for detail.

You do not fix that with a class.

Dr. Deming estimated that 94 percent of errors belong to the system. He also taught that training is management's job — it's one of his fourteen points, institute training on the job. Which means a retraining plan concedes something its authors may not have noticed. If people were never trained properly, whose job was that? If the training existed and didn't take, who selected it, designed it, and scheduled it for the last hour of a night shift?

Retraining answers a question about the worker. The question was about the system, and the system includes the people who own the training.

What Nurses Say to Each Other

This is the second post I've written from a thread on the r/nursing subreddit where someone asked about the worst medication errors people had seen. I can't verify any of it — anonymous, some of it secondhand, none of it with an investigation attached. I read it as evidence of what nurses say to each other, not as evidence of what happened.

The reflex is all over it.

An agency nurse gives a patient in anaphylaxis epinephrine 1:1000 by IV, along with everything else the PA had said out loud, and walks away. The patient goes into ventricular tachycardia and survives. The countermeasure: the entire department is in-serviced on the administration and indications for epinephrine.

A nurse practitioner places a chest tube into a baby's pulmonary artery. The baby dies. NPs are no longer permitted to place chest tubes.

A nurse connects a nebulizer straight to a trach instead of using a trach collar. The patient blows pneumothoraces and codes and survives. Nurses are no longer permitted to give nebs to trach patients.

In a skilled nursing facility, medications arrive at night in boxes for nurses to put away. A nurse can't find the colleague with the key to the locked memory unit, so she leaves that portion of the meds on top of a cart inside it. A resident who walks freely and eats what she finds eats about thirty-five of them. She survives. The nurse is fired.

Look at how many of those are restrictions rather than redesigns. Take the task away from the person who failed at it. Nothing about the boxes arriving at night. Nothing about the other nurse being unreachable. Nothing about improving the system.

Then, buried in the thread, a nurse mentions that she now types “Midazolam” into the cabinet instead of “Versed,” because vecuronium is stocked in the same cabinet and she doesn't want those two names next to each other on a screen. She doesn't want a patient to die as occurred at Vanderbilt in a famous case.

That's a good idea. It's hers. She told Reddit. I'd be she never told her hospital or her hospital had nowhere to put it, and either way the vecuronium is still in that cabinet on every shift she isn't working. When she transfers, the idea goes with her.

Two other comments describe something different. After a nurse aspirated a calcium channel blocker out of a gel capsule and gave it via IV, and the patient died. The pharmacy began sending the drug up pre-drawn in medication cups. Somewhere else, after an insulin overdose, insulin vials stopped leaving the med room.

In both cases, nobody had to remember anything. They improved the system.

Thao said she had no business taking that epidural bag out of the locker. Maybe she didn't. But a bag you're not supposed to take out isn't a countermeasure, it's an instruction, and it fit the IV line before she took it out and it fit the IV line afterward.

There is a connector now. The standard was published in 2016, ten years after Jasmine Gant died. A syringe built to it will not mate with an IV line — not shouldn't, won't. Japan has converted every hospital in the country. When ISMP wrote about it in 2020, California was the only American state that required it.

In the decade between 2008 and 2018, the FDA received 133 reports of neuraxial misconnections. Fifty-six involved intravenous tubing connected to neuraxial access. Five patients died.

Every one of those hospitals could have shown you a sign-in sheet.