The Potato Incident: Lessons Learned

• 3/17/2009
• Author: Jim Parker
• Category: Perspectives on Patient Safety Blog
• 31705 Views
• 5 Comments
• 

• Greetings!
   
  A recent experience I had with a health care organization got me thinking about infection control, leadership, patient empowerment, and the importance of a collaborative work environment.
   
  It all began with a potato.
   
  The humble tuber’s time had come.  My family and I were going to eat it.   But this potato would not go gently into that good night.  In the act of peeling this potato, a hearty portion of one of my fingertips was peeled off as well.  (We wound up not eating the potato.)
   
  As the wound continued to bleed the following morning, I let my wife talk me into going to a local urgent care center to have it looked at.  After a lengthy wait, I went back to the exam room and got all bandaged up.  The physician put a piece of mesh over the wound to help stop the bleeding, but said I should return the next day to have the mesh removed because it could interfere with healing. 
   
  My experience the next day is what got me thinking. I was seen by a different physician that day, as is often the case in urgent care.  That wasn’t a problem. The problem was that I had a great deal of difficulty getting the staff in the office that day to understand what it was that the staff from the previous day had done.  The nurse checked the records from the previous day, but that shed no light on the matter. After I spoke to three staff members, including the physician, I was able to make clear that I needed the mesh removed from the wound. 
   
  The physician decided the best method would be to soak the affected area in warm water. This was fine by me. After about 20 minutes, a nurse came back and perceived that the mesh was breaking apart, and although some of it was coming off , some of it was sticking to the wound.  The physician returned and decided to remove the sticky bits with tweezers. 
   
  The physician picked up his tweezers, took my hand, and leaned in to start picking, when someone spoke:
   
  “Doctor, shouldn’t you put on gloves?” 
   
  It was the nurse. She couldn’t have been older than her mid-twenties and had mentioned at one point that she was new to the organization. The physician, meanwhile, was advanced in years and was clearly the more experienced of the two health care providers in the room.
   
  The physician paused and—without looking at the nurse—responded that he didn’t think he needed gloves. The nurse clammed up.   
   
  Luckily, the patient in this case (me) had some familiarity with Joint Commission standards and requirements, including the following:
  
  
• • National Patient Safety Goal 7: Reduce the risk of health care–associated infections.
• • National Patient Safety Goal 13: Encourage the active involvement of patients and their families in the patient’s own care as a patient safety strategy.

1. 1. Hand hygiene. Hand hygiene remains a problematic issue in health care organizations. Several accreditation programs continue to see double-digit noncompliance rates with NPSG.07.01.01.  Organizations need to take pains to ensure that staff wash their hands to protect themselves and patients from infection. Look for new articles Perspectives on Patient Safety in 2009 that address hand hygiene and other key infection prevention and control practices.
   
   
2. 2. Leadership. Leadership. Leadership.  Leadership comes in many forms. When The Joint Commission uses the term in its standards, it is usually referring to organizational leadership, such as the CEO, the organization’s board, and so forth. However, there is what I will call “the leadership in the room” and “leadership in practice.”   In the above scenario, the leader in the room was the physician. The CEO and board members were not there, and the physician was the medical authority in the room. However, the leader in practice was the nurse. Why? Because she took the initiative to speak up when the proper procedures were not being followed. She, in essence, took the lead by trying to steer the process in the right direction.
   
   In recent years, a plethora of patient safety leaders and experts have advocated for clinicians to adopt a collaborative work environment, in which the team is focused on the patient and on adhering to best practices, in which the voice of every team member is respectfully heard without regard to organizational hierarchy or, to be frank, an individual’s ego. While this idea is starting to gain ground in health care, the concept is not new. The Chinese philosopher Lao Tzu in the 6^th Century B.C. wrote:  "To lead people, walk beside them ... As for the best leaders, the people do not notice their existence … When the best leader's work is done the people say, 'We did it ourselves!'”
   
   
3. 3. Empower patients.  When experts talk about providing health care in a collaborative work environment, it’s important to note that this includes the patient. Patients have the right and responsibility to take an active role in their own care and to ask questions when they don’t understand or agree with the treatment they are receiving. Organizations must remember to not only be receptive to patients’ questions and comments, but to encourage patients to ask questions. There is no harm in saying to a new patient up front: “You have the right to ask questions and voice your concerns about your care.” Many patients are afraid to question their health care providers; others don’t even realize that have that power. It is incumbent upon health care providers to help change these false and dangerous perceptions.