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It is a fact of life that the squeaky wheel gets the grease, but that should not be true when it comes to patient safety. Risk management experts caution that the most compliant, seemingly satisfied patient can be the one who ends up suing for malpractice if that easygoing demeanor leads staff to lower their standards.
Patient safety can be threatened when a patient is compliant and does not complain, notes R. Stephen Trosty, JD, MHA, CPHRM, president of Risk Management Consulting in Haslett, MI, and a past president of the American Society for Healthcare Risk Management (ASHRM) in Chicago. Trosty cautions risk managers to educate staff about the risks posed by an easygoing patient, especially if the staff is pushed to the breaking point. When there are not enough hands to go around, it might be the "nice" patient who is neglected, he says, but the fact that the patient seemed satisfied will be no defense in a malpractice case.
Consider the hypothetical case, prompted by actual incidents, of an elderly man admitted to a hospital for routine surgery. On the first day of recovery, family members complain that he is being neglected by staff. Surprisingly, multiple staff members divulge that the hospital is short-staffed on weekends and therefore unable to provide all the expected care.
Physical therapy is not provided twice a day as scheduled, the patient is not encouraged to use the spirometer, he is not offered aid to get to the bathroom, and he is left sitting in a chair all day because he told staff he was "fine" and did not complain about being left there. At one point, staff fail to respond to calls for walking assistance for 45 minutes, and when help finally comes, the patient has soiled himself. Despite all this, he tells family members that "the staff were just as nice as could be."
The family understands that the man's personality is such that he is unlikely to complain about his care, and he also has little understanding of what constitutes neglect. If the patient suffers any adverse event or poor outcome, the family and plaintiffs' attorneys will understand that his care was substandard whether he wants to complain or not.
And if a malpractice lawsuit results, the hospital would be ill-advised to defend itself by saying the patient was satisfied, Trosty notes.
The problem is not the patient, of course, but the natural human tendency to respond most to those asking for assistance or complaining about the quality of care. Though understandable, that tendency must be overcome with professionalism, scheduling and adequate staffing, Trosty says.
"It should not make any difference what type of patient you have in terms of receiving care. Care should be provided on set schedules, based upon patient needs and regular rounds of staff," he says. "The answering of call buttons should have nothing to do with the cooperativeness of patients. If it does make a difference, then a problem with staff has been identified. If staff do let it matter, then they have to be violating existing policies or at least policies that should be in place regarding responding to the needs of all patients."
That approach will work until staff members are overwhelmed by multiple patient needs occurring at the same time, Trosty notes, and then it is probable that the cooperative patient might not receive the first response. Attention might instead be directed to the patient or whose family is the greatest complainer.
That situation should exist only in extreme circumstances and rarely, if at all, Trosty says. Routine care must never be allowed to lapse because the patient is too nice to complain. If it does, Trosty says, the hospital is critically understaffed or the staff is unprofessional — or both.
Staff members should be reminded that their "dream patient" could be the one who ends up injured and suing the hospital if they let their guard down, says Jane McCaffrey, DFASHRM, MHSA, director of compliance and risk management at The Blood Connection in Greenville, SC, and a past president of ASHRM. "There are protocols that need following, and missed therapies need immediate evaluation," McCaffrey says. "Any facility that has staff providing quality care based on who complains the loudest has bigger problems, and I doubt any patient got what was needed."
McCaffrey takes the notion a step further and wonders about the negative impact of patient satisfaction initiatives such as not turning on a light at night to check on a patient or turning down alarms or overriding them. Those strategies might be designed to improve patient satisfaction scores, but McCaffrey wonders if they threaten patient safety by encouraging staff members not to bother the patients who seem content.
She is not the only one to wonder about how much to let sleeping patients lie. John C. Metcalfe, JD, FASHRM, vice president of risk management services with MemorialCare Health System in Fountain Valley, CA, recalls hearing of a related issue from the risk manager of another California facility. In that hospital, a patient care attendant elected not to turn on a bedside light to fix a lead on a female patient. The patient was extremely startled and thought that the attendant was doing touching her inappropriately. She was upset even after the charge nurse told her that the man was fixing the lead at his direction.
Not turning on the light and ensuring that the patient was awake prior to touching her became an allegation of abuse investigation and reportable event. As a result, Metcalfe says the nursing educator for acute care services at the facility in question now conducts educational role playing for this scenario.