Passing the buck

September 1, 2020

 

 Portland, Maine— A Johns Hopkins’ study published in 2016 estimated there are at least 250,000 annual deaths in U.S. hospitals related to medical errors. The complex coding and billing systems in the U.S. contribute to the challenge of documenting the precise number of deaths that are traced to errors. 

 

Medication errors are a significant component of preventable deaths due to errors in hospitals. There are tens of thousands of deaths related to medication errors every year in the U.S.

 

Although hospitals don't like to discuss this topic publicly, it is very real and virtually every hospital has experienced unnecessary deaths due to medical errors. The good hospitals and practitioners will try to learn from mistakes made to improve future processes and outcomes.

 

As CEO of a hospital, you have responsibility for everything that happens in the hospital. Like the captain of a ship, good or bad you are solely responsible. President Truman said it best, “The Buck Stops Here!” When outcomes are good, you have contributed to them based on the people you've hired and the policies you've put in place. When something bad happens, you own that, too, as the people hired and processes you've put in place have played a role in the outcome.

 

This true story is about the time I learned a lesson on the consequences of passing the buck.

 

A couple of decades ago at one of my first CEO appointments, the team I had assembled was coming together and performing very well. Admissions were increasing. We had hired some new physicians and the finances were improving. HR was humming and the clinical division was working together and taking care of our patients, living up to the great tradition of the organization.

 

There was a national shortage of nurses and our Medical-Surgical Unit had some openings for registered nurses. The pressure to fill open positions to eliminate overtime and agency costs was intense.

 

The Med-Surg manager had an RN candidate he wanted to hire. The HR did a background check with the State Board of Nursing and found that the RN had once been disciplined by the State Board of Nursing. No further information was available about this specific discipline.

 

The HR executive met with the chief nursing officer and asked to hold off on hiring this particular RN until the background check was completed. But the Nursing Division wanted to hire the applicant immediately to fill the void in the unit. This resulted in an impasse between the CNO and HR executive.

 

Consequently, they requested a meeting with me to discuss this matter in detail. I was presented with the arguments by both sides. In response, I replied, "You guys work it out.”

 

You guys work it out?

 

After leaving my office, HR and Nursing continued debating. Nursing finally prevailed, so the RN candidate was hired.

 

A few weeks after the new employee's orientation, that new nurse was working the night shift on the Med-Surg Unit. A patient who had been in for a routine overnight stay after surgery developed some pain during the night. This nurse contacted the patient's surgeon who ordered an additional medication to deal with the pain. The new nurse accessed the wrong medication, which was then administered. As a result, a little while later the patient had a cardiac arrest. While the patient was revived, his brain had been damaged, resulting in a coma.

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A couple of days later, I went alone into the ICU room of this gentleman, who had entrusted his life to us. As I held his hand, I prayed for his healing and also asked him to forgive us. I received several impulses as I was holding his hand. I will always believe that he heard my prayer and forgave us.

 

Unfortunately, the specialists were not able to save him. He passed away a few days later.

 

Of course, a root cause analysis was done which outlined all the clinical aspects of this case and the mistakes made. While the quality analysis details had several takeaways, my personal takeaway was that this nurse would never have been hired had I done my job.

 

However, life is about learning and this tragic outcome taught me a valuable lesson on leadership. I will never again pass the buck onto someone else when a decision comes for me to make; the experience of this patient's death will never leave me.

 

From this incident our hospital team developed a passion for safety, quality of care and exceptional outcomes.

 

As a result, our hospital became the first hospital in the state to implement a bedside medication verification system that significantly increased patient safety and for the next four years we led the state in medication safety performance.

 

I've had the opportunity to share this experience with several healthcare leadership teams and would like to think that my experience has helped many others avoid the tragic mistake I made of  “passing the buck.”

 

Theodore Lewis is former CEO of Guam Memorial Hospital and has a healthcare consulting business based out of Portland, Maine.  He is collecting stories about lessons learned in life and can be reached at theodorelewis@yahoo.com.

 

 

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