Understanding Health Policy by Thomas Bodenheimer & Kevin Grumbach

Author:Thomas Bodenheimer & Kevin Grumbach
Language: eng
Format: epub
Publisher: McGraw-Hill Education
Published: 2012-07-14T16:00:00+00:00

Health Care Systems and Quality of Care

The personnel cutbacks were terrible; staffing had diminished from four RNs per shift to two, with only two aides to provide assistance. Shelley Rush, RN, was 2 hours behind in administering medications and had five insulin injections to give, with complicated dosing schedules. A family member rushed to the nursing station saying, “The lady in my mother’s room looks bad.” Shelley ran in and found the patient unconscious. She quickly checked the blood sugar, which was disastrously low at 20 mg/dL. Shelley gave 50% glucose, and the patient woke up. Then it hit her—she had injected the insulin into the wrong patient.

Health care institutions must be well organized, with an adequate, competent staff. Shelley Rush was a superb nurse, but understaffing caused her to make a serious error. The book Curing Health Care by Berwick et al (1990) opens with a heartbreaking case:

She died, but she didn’t have to. The senior resident was sitting, near tears, in the drab office behind the nurses’ station in the intensive care unit. It was 2:00 AM, and he had been battling for thirty-two hours to save the life of the 23-year-old graduate student who had just suffered her final cardiac arrest.

The resident slid a large manila envelope across the desk top. “Take a look at this,” he said. “Routine screening chest x-ray, taken 10 months ago. The tumor is right there, and it was curable—then. By the time the second film was taken 8 months later, because she was complaining of pain, it was too late. The tumor had spread everywhere, and the odds were hopelessly against her. Everything we’ve done since then has really just been wishful thinking. We missed our chance. She missed her chance.” Exhausted, the resident put his head in his hands and cried.

Two months later, the Quality Assurance Committee completed its investigation.… “We find the inpatient care commendable in this tragic case,” concluded the brief report, “although the failure to recognize the tumor in a potentially curable stage 10 months earlier was unfortunate….” Nowhere in this report was it written explicitly why the results of the first chest x-ray had not been translated into action. No one knew.

One year later.… it was 2:00 AM, and the night custodian was cleaning the radiologist’s office. As he moved a filing cabinet aside to sweep behind it, he glimpsed a dusty tan envelope that had been stuck between the cabinet and the wall. The envelope contained a yellow radiology report slip, and the date on the report—nearly two years earlier—convinced the custodian that this was, indeed, garbage … He tossed it in with the other trash, and 4 hours later it was incinerated along with other useless things. (Berwick et al, 1990)

This patient may have had perfect access to care for an illness whose treatment is scientifically proved; she may have seen a physician who knew how to make the diagnosis and deliver the appropriate treatment; and yet the quality of her care was disastrously deficient.

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