Focus on personnel, not system

[Bob Clements <clementz@kos.net>]

With the author's permission:

Focus on personnel, not system
Sharon Shore
SPECIAL TO THE STAR

 Any system can be improved upon. Those that work well can always become
better, and those that don't work can be made functional and effective.
The coroner's jury at the Sanchia Bulgin inquest has developed 31
recommendations which, if implemented, will go a long way toward
preventing a recurrence of many of the mistakes that led to Sanchia's
death. 

  On a personal level, however, I find a number of the recommendations
very disturbing. The first one proposes that the entire health-care
system adopt the "systems approach" to patient safety.

  This approach defines all errors to be the result of systems problems.

  According to its devotees, the only acceptable solutions are to change
the workplace; one must never discipline or fire an employee. A wholly
blame-free philosophy is nothing more than a "get-out-of-jail-free" card.

  No matter how much you improve the system, if you don't get rid of the
people who aren't capable of doing the job, then you will never, ever
fix all of the problems. 

  Some of the recommendations from this inquest are almost identical to
those made by the Lisa Shore inquest jury in February, 2000.

  Consider Shore recommendation No. 11: Annual education for anyone
caring for patients receiving narcotics, including review of normal and
abnormal parameters for vital sign assessment. Bulgin jury
recommendation No. 19 proposes that Sick Kids teach its nurses how to
identify significant changes in vital signs and the early detection of
clinical deterioration.

  Why should two separate inquests recommend that the hospital teach its
nurses to be nurses? Command of the basic skills of a profession should
be a given.

  Shore recommendation No. 17 was that nursing flow charts be
periodically audited, with particular attention paid to monitoring.

  Bulgin recommendation No. 12 is for the charge nurse or preceptor (a
senior nurse responsible for training novices) to initiate daily reviews
of the flow charts and provide novice nurses with verbal feedback on
their charting and assessment skills.

  The Shore recommendation was an attempt to solve the problem of nurses
who were not charting appropriately. If the Bulgin jury has to make the
same recommendation again, the problem was obviously not fixed.

  Moreover, the problem is not restricted to novice nurses; Lisa's nurse
had 14 years of experience.

  Shore recommendation No. 16 was for the hospital to adopt the
"electronic monitoring guidelines."

  Sanchia's jury proposed in recommendation No. 11 that the electronic
monitoring guidelines be reviewed, and emphasized the need to fully
assess the patient rather than the monitoring equipment.

  Both juries were attempting to fix the same problem: nurses who forgot
the patient takes priority over all else.

  Inquests cannot lay blame, so inquest juries often must skirt the real
issues when making recommendations.

  It seems that beneath the well-intentioned suggestions for improvement
lies a strong condemnation of nursing practices on Ward 5A/B of the
Hospital for Sick Children.

  Patient safety at the Hospital for Sick Children will continue to be
jeopardized until something is done about unsafe practitioners. 

  You cannot fix the system without a strong foundation of competent and
responsible health-care professionals. 

 Sharon Shore's 10-year-old daughter Lisa also died unexpectedly at the
Hospital for Sick Children on the same ward in 1998. An inquest jury
returned a finding of homicide in Lisa's death. Sharon Shore lost her
battle to participate in the Sanchia Bulgin inquest.