Programming errors led to overdoses with pain-medicine pumps
Building off a state health department report showing that, as The Morning Call’s Tim Darragh wrote, “Nurses at St. Luke’s Hospital three times in 2010 and 2011 improperly programmed patient-controlled pumps to deliver pain medication, causing patients to overdose themselves,” Darragh dug deep into each incident, uncovering patient details and adding perspective to the errors, which were severe enough that the feds decided the hospital’s patients were in “immediate jeopardy” until steps were taken.
Photo by Felix42 via Flickr.In each of those cases and in three others, the nursing staff failed to document the errors properly, state investigators found.
Employees told the investigators that St. Luke’s did not require annual competency training on the pumps. Unnamed employees offered conflicting statements about when and whether all the staff had received retraining in 2010.
For their part, hospital officials say they have bought new patient-controlled pumps, developed a restricted dosage plan and retrained staff.
“When St. Luke’s nursing staff members identified the dosing pump programming issues, the events were promptly reported to all the appropriate individuals and regulatory agencies as outlined in our Network Patient Safety Plan,” said Carol Kuplen, chief nursing officer for St. Luke’s Hospital & Health Network.
“There was complete transparency in these events,” she said in an interview Thursday.
Related
Jeffrey Shuren, director of the FDA’s Center for Devices and Radiological Health, appeared at a newsmaker briefing at Health Journalism 2010 to announce an FDA initiative to reduce risks associated with infusion pumps. Log in to the AHCJ website to see his presentation and listen to his announcement.
- Press release: FDA Launches Initiative to Reduce Infusion Pump Risks
- FDA page on infusion pumps and FDA’s new safety initiative
- White Paper: Infusion Pump Improvement Initiative
- Guidance for Industry and FDA Staff - Total Product Life Cycle: Infusion Pump - Premarket Notification [510(k)] Submissions
- Letter to Infusion Pump Manufacturers
- Public Meeting: Infusion Pump Workshop, May 25-26, 2010
- Generic Infusion Pump Project
Navigators work to keep patients from falling through cracks
Filed under: Hot Health Headline, Nursing, Public health
Patient navigators - “like the air traffic controllers in health care” - captured the attention of Pamela Fayerman of the Vancouver Sun.
Fayerman explains that patient navigators are specially trained health care providers who help patients get access to care and services they need, serve as liaisons between patients and doctors and generally ensure patients don’t fall through the cracks of a complex health care system.
Fayerman’s five-day, multiplatform series on patient navigators was published last week and is a comprehensive look at this relatively new practice being applied to Canadian patients. She explores the roots of patient navigation in Harlem and goes on to document the evolution in Canada over the past decade.
In a story about one patient, Fayerman shows how the role of a navigator in getting efficient treatment, follow up and having a point of contact got the patient into the hospital for triple bypass surgery before she had a heart attack and sustained damage to her heart.
Other stories look at how navigators bring a culturally sensitive approach to treating members of the aboriginal community, as well as the unwillingness of Canadians to pay out of pocket for navigators, but:
In the U.S., where people are used to paying for health care, navigators are becoming more and more common - in both insured and non-insured settings and at for-profit and non-profit hospitals.
Fayerman, who used a $20,000 grant from the Canadian Institutes of Health Research, visited five provinces and 12 cities over eight months, interviewing nurse and other navigators, their patients and health system leaders. She explains why the series is important and how patients can be their own navigators.
Member’s book for nurses is published
“Anatomy of Writing for Publication for Nurses,” written by AHCJ member Cynthia Saver, R.N., M.S., has been published by Sigma Theta Tau International. Saver is the president of CLS Development Inc., an editorial consulting firm.
Send us your latest news
Got a new job? Earned a promotion? Won an award or fellowship? Just published a book? AHCJ members are encouraged to share your news by sending it to info@healthjournalism.org. Member news items are published on Covering Health and in HealthBeat, AHCJ’s newsletter.
ProPublica guides reporters to check local boards
Filed under: Government, Health data, Health journalism, Nursing, Public records, Tools
For those of you who have followed the ongoing investigation ProPublica’s Charles Ornstein and Tracy Weber have done into nurses and whether states are reporting disciplinary actions, you might have a chance to localize the story.
ProPublica has posted a guide, “Reporting Recipe: How You Can Investigate Your State’s Oversight of Its Nurses and Other Licensed Professionals,” to help reporters and the public check up on what’s happening in their states.
ProPublica editor-in-chief Paul Steiger and managing editor Stephen Engelberg, explain why they are providing the reporters’ techniques and insights:
We hope that others will use the techniques created by Ornstein and Weber to hold local officials accountable. Reporters who look into the local boards that oversee nurses or other health professionals will make new discoveries, some of which will undoubtedly go beyond what we have found. That, in turn, will help others push the story ahead. We hope statehouse reporters, beat reporters, general assignment reporters, bloggers, citizen journalists and others will use this road map.
Use the state-by-state guide prepared by Ornstein (also president of AHCJ’s board of directors) and Weber that shows what information is available to the public in each state and specific things to look for in the records.
They have used the data to identify some states that appear to be inconsistent in reporting disciplinary actions against medical professionals. If you are covering any of these states, you should probably be looking into the story yourself:
- Florida
- Georgia
- Illinios
- Indiana
- Kentucky
- Michigan
- Mississippi
- New Jersey
- Ohio
- Tennessee
- Wisconsin
- West Virginia
Nurses face dangers of workplace violence
Marlene A. Prost, writing for Human Resource Executive Online, reports that workplace violence is a growing problem for nurses.
She cites reports from Australia and the United States showing that about half of nurses in two surveys had been punched or otherwise assaulted in the past year. It appears the assaults are coming from patients and their families and friends.
However, Prost reports, nursing and hospital associations are taking notice and action, such as “improving security, encouraging incident reports and fighting to strengthen state laws to prevent violence and punish offenders.”
Hospitals are using guidelines from The Joint Commission, the Occupational Safety and Health Administration and the National Institute for Occupational Safety and Health to make nurses safer. They also are training nurses to defuse volatile situations and encouraging them to report incidents, according to the article.
Reporters may be able to find more information through the Bureau of Labor Statistics and the American Nurses Association also has information about workplace violence. The Joint Commission issued a Sentinel Event Alert in 2008 about intimidating and disruptive behaviors in the health care environment.
Selden Ring finalists explored nurses, caregivers
Two stories about caregivers were finalists for the 2010 Selden Ring Award for Investigative Reporting:
- “When Caregivers Harm,” a collaboration between Maloy Moore of the Los Angeles Times and Charles Ornstein and Tracy Weber of ProPublica, exposed significant flaws in the oversight of California nurses with disciplinary problems.
- “Trust Betrayed,” a series produced by Sally Kestin, Peter Franceschina and John Maines of the South Florida Sun Sentinel, revealed inadequate screening of caregivers with criminal histories.
The award, with a $35,000 prize, recognizes published investigative reporting that has brought results.
Nurses push to make up for physician shortages
Kaiser Health News’ Andrew Villegas reports that the nation’s 125,000-plus nurse practitioners (and physician assistants, certified nurse midwives and dental therapists) are stepping up to fill the void created by America’s shortage of primary care physicians.
The Association of American Medical Colleges projects that the shortage of primary care physicians will reach 46,000 by 2025 and it will only increase if health care reform efforts succeed and millions of Americans are added to the ranks of the insured, Villegas writes. Nurse practitioners typically handle basic services such as physical exams, common health issues and some drug prescriptions.
Debate over national health overhaul legislation has heightened the sense of urgency about primary care and given nurses ammunition for their argument. “The biggest group of clinicians that will be in shortage with universal (insurance) coverage will be those who provide primary care — and that’s what nurse practitioners are so extraordinarily good at,” says Mary Mundinger, dean of the Columbia University School of Nursing.
There is precedent: Massachusetts’ 2008 health insurance overhaul recognized the 5,600 nurse practitioners as primary care providers who would be reimbursed through private insurance and Medicaid at the same rates as doctors. The nurses, however, must work under written protocols that designate a physician who can provide medical direction.
Despite questions from the American Medical Association, proponents argue that practitioners, who are typically required to have a master’s degree in nursing and work under a doctor’s supervision, know their limits and have proven their competence and effectiveness over several decades.
Problem nurses move from state to state
Filed under: Health journalism, Hot Health Headline
ProPublica’s Charles Ornstein and Tracy Weber have, with the help of the Los Angeles Times‘ Maloy Moore, released the final installment in their nurses series (full series: ProPublica | LA Times), this one focusing on how “caregivers with troubled records can cross state lines and work without restriction.” They found that a large number of these cross-state issues could be prevented if state regulators took advantage of readily available information.
By simply typing a nurse’s name into a national database, state officials can often find out within seconds whether the nurse has been sanctioned anywhere in the country and why. But some states don’t check regularly or at all.
The failure to act quickly in such cases has grave implications: Hospitals and other healthcare employers depend on state nursing boards to vouch for nurses’ fitness to practice.
The reporters found an army of examples, from the disturbing anecdote they lead with to the 117 California nurses whose licenses had been revoked, suspended, denied or surrendered elsewhere or the 10 nurses who were disciplined in Rhode Island, yet operated with clear licenses in neighboring Massachusetts.
Most of these transgressions are recorded in a federal database, as well as in one operated by the National Council of State Boards of Nursing. Both are incomplete, even though states are required to update the federal database within 30 days of a disciplinary action. And the federal database, while more complete, is rarely used, probably because it costs money while the state boards’ database is free. Some states only check these databases when licensing a nurse the first time, others rely on the nurses themselves to disclose their own problems. A handful check their nurse list against the database regularly, but they appear to be in the minority.
Temp agencies a haven for problem nurses
Filed under: Hospitals, Hot Health Headline, Nursing
Calling it a “free-wheeling, $4-billion industry” fueled by the nation’s chronic nursing shortage, ProPublica reporters Tracy Weber and Charles Ornstein take on the firms that supply temporary nurses to American hospitals (Los Angeles Times version here). In the story, the reporters say they “found dozens of instances in which staffing agencies skimped on background checks or ignored warnings from hospitals about sub-par nurses on their payrolls. Some hired nurses sight unseen, without even conducting an interview.”
Although the healthcare system as a whole is increasingly regulated, the nurse staffing industry remains a Wild West. No one knows how many agencies exist nationwide; estimates range from 3,000 to 6,000.
Ornstein, AHCJ’s president, and Weber found plenty of cases to back up that ‘Wild West’ impression. In some cases, firms shift problem nurses from hospital to hospital as trouble arose and, even when a nurse was tossed from one temp firm, he or she usually had no problem finding work at another. Nurses were hired with criminal backgrounds and licenses that were revoked in other states. They often allow employees to prove their “competency” through online tests, and are sometimes fly-by-night operations run by people with no prior nursing experience.
In the end, the reporters found that while there is a clear divide between the best and worst temporary nurse staffing organizations, it’s not always easy or possible for hospitals to figure out which is which.
Calif. nurse rehab program full of holes
ProPublica’s Tracy Weber and Charles Ornstein follow up their investigation of California’s nursing oversight with a story about the failures of the state’s nurse rehab program (Los Angeles Times version; ProPublica version). The embattled California Board of Registered Nursing has touted the program as a safe haven where otherwise good nurses can free themselves of bad habits, but Weber and Ornstein have discovered that nurses often don’t complete the program, and sometimes continue bad behavior unabated despite the voluntary, confidential program’s required drug tests and treatment.
The team has reinforced its data-driven story with well-chosen anecdotes and observations. Program proponents argue that Weber and Ornstein are focusing on a few failures and ignoring the more numerous success stories, but the reporters show that the failures are due, at least in part, to flaws in the program. Even nurses designated as a “public risk” often aren’t investigated until more than year after earning that dubious distinction.
The reporters’ sum up the problem thus: “At the moment, the main person responsible for protecting the public from a drug-addicted nurse in California is the drug-addicted nurse. It’s a risky honor system.”
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- Data gives depth to investigation of patient safety
- What reporters should know about Alzheimer’s and related dementias
- Apply for fellowships to attend Health Journalism 2012
- AHCJ asks Supreme Court to permit broadcast of arguments in health reform case
- Tips for print, online journalists to embrace broadcast opportunities
- Numbers reveal how often, or how rarely, states check doctors’ disciplinary records
- How I did it: Falsified charts in nursing homes linked to patient care
- Access Denied: Looking at a lack of health care availability
- Transparency & medical errors: Public reporting of patient harm is a potent force
