Don’t Kill the Messenger

April 28, 2016    |   By: Alex Christgen, BS, CPPS, CPHQ

Medscape recently published an article about a nurse who was disciplined after reporting patient safety concerns arising from care provided by another nurse.  Clinical staff members who report each other for safety concerns are usually at the center of a multi-layered bundle of concerns.

  1. Does the organization support reports of safety concerns?
  2. Is there a mechanism for a non-punitive investigation of the event?
  3. Are there subsequent efforts to address system concerns related to the event?
  4. Is there a Just Culture that examines the choices made by all care providers?
  5. When a clinical care provider’s care is deficient, does the organization respond in a way that signals its dedication to good care?
  6. Does the organization “set up” the reporter as the bad guy, or does it thank them for the opportunity to investigate possible concerns?

In the case described in the article,  Nurse A (the reporter) knew the patient well and was concerned when he heard that the patient died overnight. So, he looked into the circumstances of the man’s death. He found that the patient had received a larger- than-usual insulin dose at 9:00 PM. The patient was found on the floor at 1:30 AM in a pool of vomit and diarrhea. There was no record of Nurse B checking on the patient between 9:15 PM and 1:30 AM. There was no record of a blood glucose check after 9:00 PM or of evaluation by a physician or the physician assistant on call. No fall protocol was initiated. No neurologic examination was conducted. The patient died later that morning.

Nurse A wrote an internal memo, called a “variance and concern report,” to his supervisor, expressing concerns about the large dose of insulin and the failure to assess the patient at a number of points during the night.  This was the first time he had filed such a complaint about another nurse. Within a week, Nurse A was cited (for the first time) for two technical infractions. Within 6 weeks there was a third, and he was terminated.

Eventually, Nurse A sued the organization and prevailed in his efforts to get his job back and substantial compensation for back pay.  But is this a place where you would want to work?  Or get care?

How can you find out if your organization is vulnerable to this sort of outcome?  The AHRQ survey of Patient Safety Culture can identify key safety culture challenges and opportunities in hospitals, nursing homes, medical practices and other outpatient entities.  Just Culture can provide a framework for working on concerns that come to light.  For information on either one, contact CPS.

Buppert C, “Two Nurses Who Spoke UP, Lost Their Jobs, and Sued,” accessed April 26, 2016 at  Free registration is required for access.


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