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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.
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