Errors of Omission: How Missed Nursing Care Imperils Patients

The American Nurses Association is the only full-service professional organization representing the interests of the nation’s 3.4 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on healthcare issues affecting nurses and the public.

American Nurses Association

8515 Georgia Avenue, Suite 400

Silver Spring, MD 20910-3492

1-800-274-4ANA

http://www.Nursingworld.org

Published by Nursesbooks.org

The Publishing Program of ANA

http://www.Nursesbooks.org

Copyright ©2015 American Nurses Association. All rights reserved. Reproduction or transmission in any form is not permitted without written permission of the American Nurses Association (ANA). This publication may not be translated without written permission of ANA. For inquiries, or to report unauthorized use, email [email protected].

Library of Congress Cataloging-in-Publication Data

Kalisch, Beatrice J., 1943– , author.

Errors of omission : how missed nursing care imperils patients / by Beatrice J. Kalisch.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-55810-631-4

I. American Nurses Association, issuing body. II. Title.

[DNLM: 1. Nursing Care—standards. 2. Medical Errors—nursing. 3. Nurse’s Role. 4. Nursing Staff, Hospital—organization & administration. 5. Patient Harm. WY 100.1]

R729.8

610.289—dc23

2015029770

The research reported in this book was largely supported by the Blue Cross Blue Shield Foundation of Michigan.

ISBN-13: 978-1-55810-633-8

SAN: 851-3481

08/2015

First published: August 2015

eBook conversion: TIPS Technical Publishing, Inc.

This book is dedicated to

staff nurses everywhere,

my heroes

Acknowledgments

Introduction

Part 1: The Problem

1. Patient Safety: Errors of Omission

2. Missed Nursing Care

3. Reasons for Missed Nursing Care

4. Variations in Reports of Missed Nursing Care by Role

5. Missed Nursing Care in Magnet Hospitals

6. International Missed Nursing Care

7. Missed Nursing Care in the Operating Room

8. Patient Reports of Missed Nursing Care

9. Patient Outcomes of Missed Nursing Care

10. Nursing Staff Outcomes of Missed Nursing Care

11. Staffing and Missed Nursing Care

12. Teamwork and Missed Nursing Care

Part 2: Strategies to Decrease Missed Nursing Care

13. Culture and Leadership Strategies

14. Teamwork Strategies

15. Patient and Family Engagement

16. Technology Strategies

Index

The research completed for this book would not have been possible without many people and several organizations. The ideas for the research reported in this book came from staff nurses and managers in many hospitals where it was my privilege to serve as a consultant. In particular, the vice president for nursing, Millie Curley, RN, MS, of Parrish Medical Center in Titusville, Florida, who supported the work wholeheartedly and stuck in there when the going got rough. Not too many nurse leaders have shown the vision that she exhibited. I feel honored to have worked beside her. Also very instrumental in the success of this work were the contributions of her direct reports— Susan Stefanov, Kathy Myer, Joann Chapman, Donna Shearer, Pat Hurley, Deb Landers, Deb Lindemuth, and the nursing staff throughout the hospital. All of these dedicated and talented people were absolutely instrumental in identifying the problem of missed nursing care and developing solutions to decrease missed nursing care. It was my privilege to conduct numerous interviews and focus groups with the staff and managers, to observe them while they worked, to facilitate workshops for strategic planning, to provide managers with leadership training, and to participate in committee work with the staff and managers.

Second, funding for many of the studies reported in this book was provided by the Blue Cross Blue Shield Foundation of Michigan. Nora Maloy, PhD, program officer, gave vital support and facilitation for this work. Without this Foundation’s support, this work would not have been completed.

Third, I want to thank the three organizations and their leaders that selected me to be the 2013–2014 distinguished nurse scholar in residence at the Institute of Medicine, Washington, D.C.: The American Academy of Nursing (Cheryl Sullivan), the American Nurses Foundation (Kate Judge), and the American Nurses Association (Marla Weston). All three of these individuals went out of their way to help me. Part of the requirements for the fellowship includes a project and this book was the result of my project. The year in Washington, D.C., was a tremendous opportunity for me to bring the research on missed nursing care and teamwork together in one volume and to develop strategies to move missed nursing care onto the policy agenda.

Fourth, my faculty colleagues at the University of Michigan who worked with me on various aspects of this research over the past 10 years were absolutely critical. Dana Tschannen, RN, PhD, collaborated with me in the early years to conceptualize the research, collect and analyze the data, and publish the results. Ada Sue Hinshaw, RN, PhD, former dean, participated in the development of a concept analysis of missed nursing care. Reg Williams, RN, PhD, was essential in the development and psychometric testing of the MISSCARE Survey. Chris Friese, RN, PhD, offered advice throughout the projects and coauthored several publications. AkkeNeel Talsma, RN, PhD, conducted research on missed nursing care in the perioperative area and contributed a chapter to this book on the subject. Michelle Aebersold also collaborated on several studies.

Another person who made a substantial contribution to this research was Gay Landstrom, RN, PhD, who was the chief nurse for Trinity Health in Livonia, Michigan and is now chief nurse at Dartmouth Hitchcock Medical Center in New Hampshire. She gathered the data for the first study of three hospitals and participated in the concept analysis, tool development, and data analysis. PhD students Suzanne Begeny Miyamoto, Christine Anderson, Henna Lee, Seung Hee Choi, Monica Rochman, Kyung Hee Lee, Ronald Piscotty, Beverly Dabney, Rhonda Schoville, Peg Mclaughlin, Sung Hee Choi, and Boqin Xie served as data collectors and analysts applying their outstanding analytics skills and knowledge to this research as well as to the writing of results. Ron Piscotty studied the use of electronic health record reminders on the incidence of missed nursing care for his dissertation and authored the chapter in this book on technological solutions. All of these students, most of whom have graduated, are truly awesome nurse researchers who will undoubtedly continue to make significant and important contributions to nursing science in the years to come. A number of master’s degree students in the Nursing Business and Health Systems program at the University of Michigan participated in data collection and analysis including Laura Shakarjian, RN, MS; Susan Wright, RN, MS; Julie Juno, RN, MS; Kate Gosselin, RN, DNP, MS; Aimee Elizabeth Labelle, RN, MS; and Katherine Russell, RN, MS. Without their contributions, this research would not have been possible. I am very indebted to them. A special thanks to Sarah Lane, RN, MS, nurse manager, who opened her unit to the testing of interventions and to all of the managers in the over 130 patient care units in my studies for their willingness to participate and for their facilitation of the research. I am also grateful to Eduardo Salas, PhD, Professor & Trustee Chair, University of Central Florida, the author of the theory upon which my teamwork studies are built, for his ongoing assistance and support. His student, Sallie J. Weaver, PhD, was also very helpful.

In addition, a number of international colleagues were outstanding to work with and made the countries comparison possible. These include:

University of Iceland, Reykjavik, Iceland: Helga Bragadottir RN, PhD; Sigridur Briet Smaradottir, Cand. Psych.; and Heiður Hrund Jonsdottir MS

Hacettepe University, Ankara, Turkey: Fusun Terzioglu, RN, PhD; Sergul Duygulu, RN, PhD; and Cigdem Yucel, RN, PhD

Lebanese American University, Beirut, Lebanon: Myrna Doumit, RN, PhD, and Joanna El Zein, RN, MSN

University of São Paulo, Ribeirão Preto, Brazil: Maria Helena Larcher Caliri, RN, PhD; Lillian Dias Castilho Siqueira, RN, MS; and Rosana Aparecida Spadoti Dantas

Princess Alexandra Hospital, Brisbane, Australia: Kerri Holzhauser, RN, MS, and Liz Burmeister, RN, MS, PhD

Kyngpook National University, Daegu, South Korea: Eunjoo Lee, RN, PhD

Azienda Ospedaliera Policlinico di Modena, the Italian Missed Care Study Group, Modena, Italy: Annamaria Ferraresi, Luisa Sist, Anna Bandini, Stefania Bandini, Carla Cortini, Massa Licia Massa, and Roberta Zanin.

I have many wonderful memories of my visits to their countries and feel very fortunate to have had them as collaborators. The quality of their participation was superb.

Last, but definitely not least, I want to give a special thanks to Betsy Hetrick, RN, MS, who painstakingly reviewed every word in every chapter, correcting errors and ensuring appropriate style. I am also thankful to Erin Walpole, the American Nurses Association editor assigned to this book, for also reading every word many times and substantially improving it. And, Joe Vallina, CAE, publisher for the American Nurses Association. Finally, thanks to Philip and Melanie, my son and daughter, whose love and affection continuously sustain me.

The content of this book addresses the problem of missed nursing care (standard, required care that is not provided), ramifications of missed nursing care, and strategies to decrease missed nursing care. The research underlying this book was the result of listening to nursing staff members and observing them at work over several years. Thanks to all of you for your contributions to this research. Addressing missed nursing care is a part of the overall patient safety movement which began to receive attention when the Institute of Medicine (IOM) published To Err is Human in 1999. This ground-breaking study reported that there were close to 100,000 unnecessary and preventable deaths each year due to errors made in the delivery of health care. Up to this point, there was a tendency to ignore errors or even to cover them up. Patients and families were not always told that something had gone wrong.

The IOM report recommended creating an environment where it is safe to report errors, meaning that errors would not lead to punishment as in the past. Only by openly reporting errors can the causes be identified and solutions developed to avoid them in the future. The report strongly recommended that the culture of blame present in most healthcare organizations be replaced with a culture of safety and teamwork where providers feel safe to disclose their mistakes, challenge authority, and ask questions of others. This report also underlined the importance of teamwork in achieving patient safety.

This early work in patient safety focused primarily on errors of commission (e.g., amputating the wrong leg, giving too high a dosage of a medication or one the patient is allergic to, etc.). But there are also errors of omission, such as omitting surveillance, not administering ordered medications, not preparing the patient and family for discharge, not ambulating, not teaching patients and families, and so forth. In fact, the Agency for Healthcare Research and Quality (AHRQ) states that there are likely more errors of omission than commission. A study of the parenteral drug administration for 1,328 patients in 113 intensive care units (ICUs) in 27 countries, 861 errors affecting 441 patients were identified. Three-quarters of those errors were classified as errors of omission (Valentin et al., 2009). In a study conducted in U.S. Department of Veterans Affairs Hospitals, errors averaged 4.7 per case, of which 95.7% represented problems of underuse (for example, inadequate diagnostic testing and the failure to obtain sufficient data from histories and physical examinations). Of the 2,917 errors uncovered in this study, 27 (97%) were rated as highly serious and 26 of these (96%) were errors of omission (Hayward et al., 2005).

The omission bias where nurses and other providers would rather do nothing than do something that causes harm contributes to errors of omission. Both of these actions—providing or not providing care—potentially cause harm, but not giving care is considered more acceptable. For example, a nurse may feel that it would be better to not ambulate a patient than to have the patient fall in the process.

Like healthcare providers in general, nurses have been reluctant to report their own and coworkers’ errors. Somehow nurses, at least when they first start to practice, believe they should be able to practice for 40 or 50 years and almost never make a mistake. I vividly remember the first mistake I made, and I was fully convinced I could not be a nurse because of it.

Nurses carry a heavy sense of guilt and experience moral distress when their patients do not receive all the care they need. In fact, the more nursing care that is missed, the higher the rate of job dissatisfaction and intent to leave their current position or occupation. Nurses want to do a good job! Because of these feelings and the culture of blame that still exists in many healthcare organizations, nurses do not readily discuss the nursing care they miss or other mistakes they make. But just like any error, unless it is acknowledged and the causes examined, the problem will not be fixed. At my presentations of this research, nurses often come up afterward and thank me for bringing this issue out in the open. They refer to it as a hidden secret. Regret and self-blame are palpable.

One of the key strategies for addressing the problem of missed nursing care is teamwork. Building a safety culture requires teamwork. Basic human behaviors lead to the normal competitiveness and pride among members of work groups and often result in defensive statements about how someone else is the problem. Nurses and other healthcare providers need to believe that if anyone fails, the whole organization or patient care unit fails. Leaders need to emphasize the word we instead of they. For example one RN says: Why do you have 4 patients and I have 5? This comment demonstrates that the most important concern of this nurse is probably herself and her workload, not the team and the patients who need care. If collective orientation is present, the response would be We have 9 patients to take care of. How can we work together to get the work done?

Hand washing is another opportunity for team accountability. Many staff members believe if they wash their own hands, that is the end of their responsibility. But they are also accountable for hand washing by everyone else on the team (if they witness it). If a teammate (e.g., nurse, physical therapist, physician, etc.) does not wash their hands and no one brings it to that person’s attention, the teammates are not fulfilling their responsibilities. Everyone makes mistakes and it takes a team to catch each other’s errors. The patient care unit staff needs to see themselves as a team which must work together and help each other to yield safe and successful outcomes. Teamwork is essential to decreasing errors including missed nursing care.

The book is divided into two sections. Part one presents the findings of the research conducted on how much nursing care is missed in the United States and in seven other countries. It also reports the reasons for missing nursing care and the impact of not completing care on patients, nursing staff, and organizations. Finally, it reports on several studies of nursing teamwork. Part two contains strategies for decreasing missed care including culture change, leadership, teamwork, patient and family engagement, and technology. Taken all together they offer the reader an in-depth view of errors of omission in nursing care and ways to diminish their frequency.

Who Should Read This Book?

This book will be worthwhile to a wide range of audiences including staff nurses, nurse executives and managers in acute and long-term care, nursing faculty and students in nurse preparation programs, healthcare administrators and chief executives of acute and long-term care facilities, researchers, physicians and other healthcare providers (e.g., pharmacy, respiratory, physical and occupational therapy, etc.), and policy makers.

Staff nurses and managers will find this book very valuable in their work of providing safe, quality nursing care. It identifies areas of missed nursing care, the consequences of not providing care, methods of monitoring and studying it, and the importance and the role of management and leadership in addressing the issue of missed nursing care. Staff nurses and managers will find the strategies outlined in the book helpful in decreasing missed nursing care in their team or organization.

The basic nurse preparation program curricula in most schools of nursing does not include content and practice in what to do when a mistake is made. Students in nursing schools, physicians, pharmacists, physical therapists, and other providers who read this book will be exposed to the high value and impact of nursing care and the problems associated with not providing it. They will gain an understanding of the science behind nursing care. Researchers will be able to identify topics in need of additional study. For example, there is a large gap in research on the impact of basic nursing care and on interventions to decrease missed nursing care. They will also learn the language of explaining the value of nursing to others, such as hospital administrators, financial officers, legislators, and congressmen, to name a few.

Administrators who read this book will gain an appreciation of the work of nurses and the difference it makes for patient and staff outcomes, thus providing a basis for resource allocation decisions. This book will give them insight into how to balance the costs and benefits. Nurse leaders, lobbyists, professional association executives, and others will also find this book useful in documenting the importance and impact of nursing care or the lack of it as they advocate for resources and policy.

There is a tendency to diminish the importance of nursing (So what if the patient isn’t ambulated or doesn’t eat for a day? What’s the big deal?). This book contains evidence that nursing care is a big deal. It also provides a strong reminder of the value of nursing care. Even nurses often lose sight of the importance of their work, given the stereotypes of nursing as the lower half of medicine, the poor media portrayals of nursing, and other factors which diminish the true importance and contributions of nurses and nursing care. What if all the nurses in the world took a day off? What would be the consequences? The impact would be far greater, and more detrimental than if all the members of other occupations took a day off. A day without lawyers, a day without accountants, a day without professors for example, would not result in the same level of harm and suffering as a day without nurses. There are three nurses for every physician, thus a day without physicians, while disastrous, would probably not be as detrimental as a day without nurses. Nurses are an indispensable and exceedingly valuable contributor to the health and well-being of society. What nurses do and the difference they make must be recognized and supported to ensure that this essential resource is available in future years and for decades to come.

The Problem

Patient Safety: Errors of Omission

A Patient Experience

The U.S. healthcare delivery system does not consistently provide high-quality nursing care to all citizens who need it. The public should be able to count on receiving at least the standard required nursing care that meets their needs and is based on evidence—yet, research shows us that this is not the case. Nursing care routinely fails to deliver its potential benefits. Indeed, between the nursing care that we now experience and the nursing care that we could have, there exists not just a gap, but what the Institute of Medicine has called a chasm.

How different the view of the hospital is from the bed of a patient. Suddenly, the paradigm is flipped, and the insights revealed about hospital care can be quite astounding. It is toward this end that I am sharing my experience as an inpatient for seven days in an acute care hospital. I was hospitalized out of town. The following does not describe everything that happened, but includes some of the major gaps in my care.

First Impressions: The Emergency Department (ED)

Arriving at the Emergency Department as most patients do, I was triaged. Not knowing what was wrong with me, just that I was in intense pain, I immediately suggested an EKG to the triage nurse. I was placed on a stretcher in the hall (no room was available) for the EKG and remained there for over two and half hours during which the only contact with staff was when my friend asked for an emesis basin which was handed to her; this staff member, who I assume was an RN, didn’t even look my way. This nurse was assigned to me but she never presented herself, despite my obvious and intense pain. My friend noted that during this time, several staff members were laughing and talking at the desk.

Finally, I was moved into an ED room. I mentioned to the nurse that she must be really busy. She replied rather briskly, giving me the impression that I was off-base: You’re lucky; yesterday it was a six-hour wait. The care I received once in the room in the ED was good. They started a morphine IV, sent me for a CT scan, and diagnosed my problem as pancreatitis.

Then, I was told that I was to be transferred to an inpatient unit. My pain was coming back; the morphine was wearing off. I asked the nurse if I could have pain medication before being transferred to the unit, knowing that once on the unit, an assessment would need to be made by the nurse and physician orders would need to be obtained before I could receive pain medication. She said Honey, you will get it when you get to the unit. Thirty minutes later, my pain was getting worse and the transporter had not shown up to take me to the unit. I asked again for pain medication and the nurse repeated that I would receive medication on the unit. Another half hour passed and no one came to take me to the unit; I asked for pain medication and again met with the same response from the ED staff. At that point, I asked when I was going to be transferred and wondered out loud if one of the ED techs could take me. Apparently, they realized at that point that I had waited a very long time for transportation (I wonder when it would have dawned on them if I had not asked the question). They decided to give up on the transporter and finally had a tech take me up 45 minutes later. As my ED room was across from the nurses’ station, I noted during my two or more hour wait that the staff were gathered at the desk, laughing and talking. So much for my first impressions!

Second Impression: On the Unit

On the unit, in my room, I waited for what seemed like an interminable time and I was in very intense pain. A nursing assistant finally came in and I asked for pain medication once again. She apparently let the nurse know because the nurse came in with the computer to do my assessment. Her first comment was No one let us know you were here! I again asked for pain medication, and she predictably said she couldn’t give me anything until she finished her assessment. I said, Well, can we hurry? She was pleasant and moved through the process quickly. After another period of time, a nurse came in with pain medication. She said, I have overridden the Pyxis to get this and I can only do it one time. I am not sure why she said this but my internal response was, Shame on me; I am getting special favors that are a great inconvenience to the staff. And don’t ask again! I hope this kills my pain!

The Hospitalists

Since I was out of town, the hospitalists were my sole physicians, except for one referral to a gastroenterologist. Over the course of the hospital stay, I estimated that I had five different hospitalists. The first one came into my room after I was admitted to the unit and said, Your pain is not exactly in the right place. I was miserable and far from the problem-solving mode. I wondered what he wanted to do. Then he said that I would be on IVs, and I could have a catheter if I wanted it so I wouldn’t have to get up to go to the bathroom. I rose out of the bed and said, NO! That would be all I needed—a urinary tract infection and more immobility. That was my last glimpse of a hospitalist for another three days. I asked the nurse why no one had come in to see me and she said, Oh, he was here. Maybe you were sleeping.

Several days into the hospitalization, a referral was made to a gastroenterologist and he ordered an upper GI for the next morning. When I arrived in the diagnostic area, the nurse questioned me several times about my pain location and finally said that I didn’t have to have the procedure if I didn’t want to. What if it was a pulmonary embolism (PE)? Not being fully capable of decision-making, to say the least, this was alarming, and I was not sure what to do. She was trying to tell me something. My oxygen saturation rate was low at 85. She was obviously coaching me. When the physician came back in, I asked him what the implications of me having a possible PE with the procedure he was about to do. He said, I shouldn’t put you under anesthesia for two hours if that is the case. Instead he ordered a CT scan where they found pneumonia. He mentioned that it was probably hospital-acquired. I never had the procedure.

Nursing Care

In order to describe the nursing care on the medical unit I was on for seven days, I have presented it in the following categories of basic care, psychosocial care, and discharge planning. Since I was too sick to evaluate medication doses or accuracy of IVs, I assume that everything was correct and on time, but given the other nursing care I received, I was anxious that there could be errors.

Basic care. As far as hygiene care, there was practically none. Being on nothing by mouth (NPO), my mouth was extremely dry and my lips were crusted (worse than I had ever experienced). I asked for ice chips but was told I couldn’t have them. I asked for mineral oil and received one small tube to apply myself. When I asked for more, they gave me a disposable mouth care packet with two swabs to stick into a cup of water which sat there for 36 hours until I asked for fresh water. I knew I should not use the same swabs over and over, but no one offered additional ones and I was too sick to ask. It seemed low on the priority list at that point.

I had only two baths (showers) during the seven days, and the second one I insisted upon (the day I was discharged). When I rang to go to the bathroom, the staff came in a reasonable time but they repeatedly scolded me that I was making a mess of my tubes, which took them time to straighten out. After about the fifth time, I said, practically in tears, I am not doing it on purpose. Shortly afterwards, the nurse came in with a Velcro cord she had taken off of the computers to tie the tubes together. I felt heard at that point.

Ambulation was also totally absent throughout the hospitalization. I turned myself and got up into the chair on my own whenever I could, but no one came to get me out of bed, much less ambulate me, through the entire hospital stay. After several days, I felt good enough to think about the need to walk, and I started out down the hall but the staff said, No, you have to have your oxygen, and chased me back to my room. So, I went back to my room, thinking they would come and assist me to ambulate but they never did, and I felt too sick to do anything about it. There was no physical therapy ordered either. Consequently, it took seven weeks after discharge in costly physical therapy for me to become conditioned again.

The issue of hand washing was revelatory. I searched the room for Purell and finally found it over in front of my roommate’s bed that was closest to the window (an odd place). I wondered why it was located so far out of the way. The staff would have had to walk in front of me to use it, and I saw only one staff member do that. I wondered if there was a sink outside my room and assumed there was because the thought that my caretakers were not washing their hands was too frightening to contemplate. Later, when I was moved to another room, I saw that there was no such sink and wondered what infections I might have acquired.

Intake and output documentation was scant at best. I often told the staff that I had used the toilet, but I didn’t see anyone measure it. I was concerned because I was aware that my output was extremely low. When I told them, they did not seem concerned. I also had received too much fluid, which was inhibiting my breathing (along with the pneumonia).

Emotional support. In terms of what I will call psychological support, staff did not listen to me on repeated occasions. In the midst of all of this missed nursing care, I had one excellent nurse intervention. I was hallucinating and asked the nurse if I could talk with her. She sat down by my bed, and I told her I was seeing things. She said: You are exhausted. Your roommate is going to be out of the room for two hours, and we will put a sign on the door to not disturb you and you can get two hours of sleep. After that I had no more mental disturbances.

Discharge planning/teaching. Through all of the hospital days, no one mentioned anything about post-discharge arrangements until the day before I finally did leave. On the sixth day, a hospitalist I had never seen before came into the room and stood by the door (as far away from me as she could get), and said, You are being discharged today. I looked at the clock, saw that it was 10:30 a.m., and asked when that would be. She said by noon. I felt panicked. The best way to describe my discomfort was an extreme bloating sensation in my chest and stomach (from over-hydration). I had also gained 15 pounds without eating or drinking much of anything. My Sat rate without oxygen was still 85%, and I had pitting edema on my ankles. I had been on oxygen 24 hours a day.

Since I was out of town and felt absolutely horrible, I was very confused as to what to do. I very much wanted to get back home, but I couldn’t imagine how I would make it. I expressed my concern to the nurse who said, Well, you can’t stay here just because you don’t feel good. Most people want to go home for Christmas. My thoughts were Not me, I want to spend Christmas right here in this wonderful environment! I also thought If I am discharged, I know I will have to come back to the ED and go through that terrible experience again. I am not sure I can make it.

Then, I received a phone call from the social worker with whom I had never had contact before this point in time. She said she lived an hour away and didn’t want to come in. She stated, You need to leave the hospital today. Somehow I felt I had been labeled a deadbeat of some kind. Her first question was Where did you come from? I answered a hotel. I said I had to get a plane reservation—frankly I was confused and anxious as to what to do. She said, Can you go back there (hotel)? I said they didn’t have a restaurant. She quickly, without listening and without giving me a chance to say what I was worried about, levied several more questions. Since they knew I was in town to get my mother into assisted living, she asked Can you go to your mother’s home? Can you go to assisted living? Maybe you can go to the assisted living your mother is going to go to. You have to leave the hospital. We have several places you can go but you can’t stay in the hospital. At that point, my anxiety was skyrocketing. I was also angry (why did they wait until now to discuss this with me?). I was so frustrated that this social worker was not giving me a chance to say anything and that she would not even listen to me. I just hung up, which is something I never do.

About 30 minutes later, the nurse came in again and said, Just because you hung up doesn’t mean you can stay here. The doctor wants me to tell you that you can’t stay in the hospital just because you don’t feel well. You haven’t been getting out of bed and walking. Now it was my fault that I was deconditioned, not the fact that ambulation had been entirely omitted in my care.

At that point the respiratory therapist appeared and saw my distress. She subsequently walked me down the hall and stayed with me for over an hour, recognizing my frustration and trying to help me deal with my anxiety. I told her I had a friend that I could stay with for a short time but her husband was very sick, and I was afraid that if I went there feeling the way I did, she would need to bring me back to the ED. It appeared that she was helpless to keep me in the hospital but she arranged for oxygen to be delivered to my friend’s house and for oxygen to take on the airplane.

My friend came to the hospital and she was clearly worried about taking me home in the condition I was in. She asked the staff why I had gained 15 pounds—she knew something was wrong with me. At this point, I had reached my wit’s end and asked to see the administrator in charge. They sent the house supervisor who came in and said, You don’t have to leave until midnight as if that was going to solve my problem of being barely able to get out of bed. My friend asked her about the weight gain and she looked puzzled. My friend talked to the supervisor for about a half hour, pleading for help with this situation.

I asked the nurse if I should have Lasix for what I felt was excess fluid. She said, We are afraid of the side effects. I asked Is there anything I can take? basically pleading for help. She answered, You are a nurse; you know the answer to that. I thought, What do I not remember. Everyone, except my friend, seems to think there is no problem.

At 7 p.m., this same nurse (going off-duty, I presume) came in and said they decided to keep me another day and I would receive Lasix . She said the night nurse would administer it, which occurred three hours later. I was thinking, I wish she would have given it to me earlier, since I imagined I would not be able to sleep getting up to the bathroom all night. I voided more than 1,500 ccs in the next several hours (although the staff did not measure my output and did not ask me about it). I felt like a new person and was able to be discharged (without oxygen).¹

There were major gaps in my care including lack of surveillance, missed nursing care, shaming and blaming, not being listened to, lack of discharge planning, and poor practices. To begin, there were gaps in surveillance. In the ED, I was ignored until I was placed in a room. No one checked on me for over two hours as I lay there waiting in pain. Then, when I was to be transported to the unit for admission, I waited unattended another few hours in pain while they repeatedly said, You will get pain medication when you get to the unit. The transport to the unit occurred 45 minutes after I suggested that a tech in the ED could take me (the ordinary patient would not have the information to know what was causing the delay—unavailable transporters). How long I would have been there had I not intervened is unknown. Once I got to the unit, my nurse was not notified of my presence and didn’t come into my room for another hour. Meanwhile, my pain was escalating. This gave me little confidence that my nursing staff were observing me. Just the opposite; I seemed invisible wherever I went!

Care was missed repeatedly. Missed nursing care, defined as any aspect of required patient care that is omitted (either in part or in whole) or delayed, is the subject of this book and was the area of research I had been working on for some time before this incident. Basic care was virtually nonexistent—ambulating, turning, monitoring intake and output, bathing, mouth care, and so forth. These were important to my well-being and are truly patient safety issues—acts of omission.

Another element of missed care was emotional support. It was not just the lack of support; the staff seemed to have a strong need to control their patients. Not being listened to by the staff proved to be a prevailing theme. Repeatedly, the staff communicated that they knew what was best and it didn’t matter what I said. It was not until I asked to see an administrator on the sixth day that someone (the house supervisor) looked at the situation from my point of view and arranged for me to receive Lasix and stay in the hospital another day. There were many instances of blaming me for problems, such as not ambulating, and telling me I should know, since after all you are a nurse. (I kept it a secret as long as I could but somehow the dean of the local school of nursing found out I was hospitalized and came to visit me. Much later she told me she talked to them about the lack of care I was receiving.) The lack of preparation for discharge was remarkable. This experience underlined the critical importance of planning for discharge early in the hospital stay.

It took me weeks, even months, to process and recover from the entire experience. I could not even write about it for a year. Although there were instances of excellent nursing care, on the whole, it was severely lacking. If nursing care had been up to standard, my illness would still have been trying, but perhaps I would not have contracted pneumonia (from poor mouth care practices, no ambulation, etc.), become debilitated, experienced feelings of shame, and run the risk of infection; I could have avoided the associated stress and anxiety. Although this could, conceivably, be a rare occurrence, I am afraid it is not. These gaps in care, or errors of omission, are not only unsafe but are also costly to the healthcare system.

The Patient Safety Movement

In 1999, To Err is Human was published by the Institute of Medicine (IOM). This study, which reported that tens of thousands of patients die each year as a result of preventable mistakes in their care, launched a national, and later worldwide, movement to increase patient safety and decrease errors. Following this study, the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century (2001). This study called for a total revamping of the current healthcare system, and the need for innovative approaches for caring for patients. It called for major changes to the healthcare system’s processes to improve the level of quality and safety. It also explored potential ways in which the required changes could be implemented. These two documents were instrumental in raising patient safety to be viewed as a major concern in health care and among policymakers.

In addition, a large number of reports, in what is referred to as the Quality Chasm Series, were issued that addressed leadership, systems issues, the health workforce, medication errors, priorities, academic health centers, health literacy, partnership with engineering, and others.

One of these reports was devoted to nursing: Keeping Patients Safe: Transforming the Work Environment of Nurses (2004). The report is significant for three reasons:

1. It documents the key role that nurses play in patient safety and makes specific recommendations for changing their work environments to