Health care professionals (HCPs) learn early in their careers that most HCPs as well as the populations they serve live under a general paradigm in which physicians, recognized differently under various jurisdictions, are the highest sources of authority within those jurisdictions. Accordingly, all other HCPs can be located on various tiers below physicians. Many go so far as to refer to physicians as health care “providers” in contrast to other HCPs, who are often thought of as tasked with the fulfillment of provider-issued orders. Is this helpful overall? Are there examples of dysfunction within health care that may be attributable to this paradigm? This week, I’d like to propose one possible area: our use of event reporting systems (ERSs).
Some form of ERS is common in contemporary health care organizations (HCOs). By an ERS, I mean a system by which an HCO tracks and learns from events and circumstances that represent suboptimal function within the system. By utilizing such a system, an organization can more effectively identify and overcome barriers to success as well as identify and enhance existing strengths.
On numerous occasions, I have utilized the ERS of my HCO to call attention to failures of various kinds, including those originating from equipment or devices, personnel, or processes and procedures. Since becoming a wound and ostomy care nurse, I have primarily utilized the ERS in cases related to hospital-acquired pressure injuries or failure of bedside staff to execute treatment orders.
Regrettably, there are cases in which I visit patients for follow-up wound assessment only to find the wounds in question, for which daily dressing changes had been ordered, either left open to air or covered with dressings I myself applied days previously. When this happens, I know there are likely a number of different factors involved in the failure. For example, staffing may be tight, and there is often little time left for what in the moment may seem like a minor task. Perhaps, a nurse forgets to mention the wound and dressing order in report, so the wound begins to go unnoticed. A patient’s hygiene care may end up being accomplished by support staff or a nursing student who does not realize the wound is an important aspect of the primary nurse’s care. Maybe a supply chain issue contributes to a lack of immediately available dressing materials. Any one (or more) of these could be responsible for failures of this type.
However, the ERS utilized by my HCO analyzes the preliminary event report during entry to predict and propose categories of failure. One of the most commonly proposed in the type of case just described has to do with “failure to perform a provider order” or something with similar phrasing. By this I presume is meant that an order, entered by or on behalf of someone with the legal authority to issue such an order, was not carried out.
Wound care orders in my HCO are issued by physicians, nurse practitioners, or physician assistants, often based on assessments and recommendations from wound care nurses, who do not have authority to issue orders. This is perfectly reasonable, in my opinion. By policy and statute, such order-issuing personnel either are providers themselves or are in the chain of providers and are therefore appropriate authorities.
That seems all well and good, but I do wonder whether or not our health care system might be better organized in such a way that nursing assessments and recommendations would exert greater influence in health care decisions made by providers. As it is, ERSs may be too heavily weighted toward provider authority with little accountability for providers. Given the seeming lack of awareness of the ERS among some physicians I have interacted with, I also wonder what relative proportions of event reports are entered by various groups of HCPs.
Would it not be prudent, even ethically sound, to report failures of providers to adequately account for nursing assessments and diagnoses in their decisions? Nursing assessments are included in patients’ permanent records. Providers often rely on nursing assessment and judgment to gather information that contributes to the decisions they make. Unfortunately, nurses may often feel powerless to object to orders that in their clinical judgment may be detrimental to their patients. They may also feel thwarted in their attempt to contribute to patient care because of resistance to the credibility of nursing among some non-nurse HCPs.
Some HCOs take the step of clarifying their chains of command. This can empower nurses, among other HCPs, through the knowledge that there are ways to communicate within their organizations that will lend weight to the role of nursing in front-line patient care and decision making. Is this enough? Should nurses pursue greater accountability for non-nurse HCPs by reporting failures to incorporate nursing assessment and judgment into health care decisions? Does the existing ERS at your HCO allow for such reporting? What would be the advantages and disadvantages of doing so? Let me know what you think.