The following Call for Manuscripts appeared in the classifieds section of Poets & Writers magazine in the March/April 2006 issue. This advertisement sought contributions to an anthology:
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If you have recently been a patient in a hospital or supported a friend or family during a serious illness, develop a fictional story based on your experiences in the healthcare system. Address errors made or almost made by care providers, other challenges, frustrations, and emotions. Provide your name, address, telephone, e-mail address, word count, biography. Deadline: April 30. Submit or write for more information about us and a list of topics[horizontal ellipsis]
The thought of such an anthology annoyed me. It seemed like it would be a book criticizing doctors, nurses, and the rest of the healthcare team. There is always someone ready to take aim at us. Healthcare is not an exact science yet the public expects perfection. In the above advertisement, not only are the writers encouraged to tell the stories of errors made, but to fictionalize (read: exaggerate) them. The criticisms would not even be truthful!!
I e-mailed the editor of the anthology, asking to hear more about her book. I said that I was interested in submitting a story, and asked that she tell me more about her book. What would the tone be? I came out and asked if this was intended to be a forum for criticizing healthcare professionals, particularly nurses.
When she wrote me back, I realized that she was a nurse too. I was relieved, and came out and asked her, nurse to nurse, whether the book would contain any "nurse bashing." Over the years, our professional image has taken enough hits, and I certainly did not want to be a party to any more.
She replied that the purpose of the book was to describe "how scary it is to be a patient these days, and what patients can do to protect themselves." Illness and surgery are inherently scary. There is a unique anxiety with elective surgery. How many times have our patients said, "What if something happens to me, and I did this to myself?" or "I feel so guilty having this surgery. I have children and I shouldn't take this risk." The relief on their faces, when they wake up from anesthesia, says it all.
Whether it is reading about them in a book, or in face-to-face discussions, there is also merit in looking at mistakes or "near misses." Picking apart the events leading up to a mistake or close call help to see what system problems need to be addressed. It seems like it is a series of small mistakes that often add up to a tragedy. Much of the safety literature is about examining the systems and human errors, large and small.
The whole idea of the patients protecting themselves is not new. When I was a surgical inpatient in 2003, I was surprised that there was a booklet in my "welcome" packet that was about the patient being partners with the healthcare team. It outlined the things patients could do to protect themselves, essentially giving the patient permission to question the doctor and the nurse about care. The premise of the booklet is that the doctor and the nurse can make mistakes, and that is not only OK but it is the patient's responsibility to participate in maintaining safety. For example, the patients should question the nurse about new medications and to please speak up if their medications do not look right. Most nurses would agree that something a patient says or does to clarify a medication should cause the nurse to take a second look at the order or make some phone calls, ultimately preventing an error. The offhand comment "Gee, I thought that pill was round" is enough to send the nurse back to the medication book.
If the patients have the right and responsibility to speak up, the nurses certainly do!! In nursing schools, many of us studied the legal case Darling v. Charleston Community Memorial Hospital (1965). This 1965 case arose at a time when there was not the culture of safety that there is today. Private physicians as well as hospital nurses cared for a patient who developed compromised circulation in a casted broken leg. Ultimately, the patient developed gangrene and a below-the-knee amputation was required. The argument against the hospital was that even though the doctor did not see the need for intervention, a skilled nurse should have, and should have called the problem to the attention of hospital authorities. The court agreed that there was enough evidence to find that skilled nurses would have recognized the progressive condition and brought it to the attention of the hospital administration for action, that is, followed the chain of command. In other words, in the right situation, a hospital might be liable if a nurse fails to bring a problem to the attention of the administration.
Throughout this issue, there are several references to "the culture of safety." The whole idea is to make our work environments a safe place to question practice because patient safety is a higher and more important goal than avoidance of repercussions. In the plastic surgery center where I work, for example, any person in the OR can call a "time out" before the case starts if he or she has any concerns about the case proceeding. The safety culture discourages negative repercussions to the individual(s) raising the concerns. Our hospital also has a "Compliance Line," a phone line to which an employee can call anonymously to signal a concern about a patient care or systems issue, and each problem is investigated. It is additional work for the administrators and managers to look into each situation, but it sends a strong message that the concerns are taken seriously.
In this issue of the journal, all of the articles and departments address safety. Each year, the editorial board chooses the topic for the "focus" issue of the following year. Even though we write about patient safety in every issue (every article has the goal of ultimately improving patient care, thus safety), the editorial board wanted to shine a light on safety. How are accrediting agencies and individuals enhancing patient safety in 2006? Whether it is informing the public about the importance of choosing a surgeon certified by the Board of Plastic Surgery, improving patient care and preventing complications, smarter ways of teaching patients, or establishing new accreditation criteria, all of us have a hand in patient safety.
Instead of fictionalized stories about healthcare, in this issue of the journal, we invite you to read about how nurses keep their patients safe.