lessons about patient safety from jean reeder

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Page 1: Lessons about patient safety from Jean Reeder

AUGUST 2002, VOL 76, NO 2

P A T I E N T S A F E T Y F I R S T

Lessons about patient safely from Jean Reeder

ean M. Reeder, RN, PhD, FAAN, was an AORN past President. Her contributions to

the nursing profession and AORN were many. She was a nurse researcher, author, lecturer, educa- tor. mentor, and nationally recog- nized authority on perioperative nursing and patient safety. Jean taught her colleagues many les- sons about patient safety and the ethical dilemmas in nursing prac- tice. She wrote and talked about patient safety long before it became a buzzword, and she was one of the first to thoughthlly consider how health care profes- sionals cope with making a med- ical error. Jean’s work has and will continue to direct AORN on the path to ensuring that surgical patients receive safe, competent, ethical care.

BEGINNINGS Jean’s lessons to nurses about

patient safety spanned her entire career. Many recognized her as a patient advocate in her various roles during her distinguished mil- itary and professional career. Her earliest published articles focus on helping patients achieve their highest level of independence and a variety of ethical issues in nurs- ing practice.’ She was one of the first to write about the specific nature of the types of dilemmas perioperative nurses face on a reg- ular basis. Areas of concern that Jean addressed include informed consent and truth-telling; alloca- tion of resources; the care of patients who are HIV positive;

advocacy for intraoperative patients; infection control; and balancing multiple, competing clinical demands.’

tion of human rights and her writ- ings from the late 1980s and early 1990s reflect her strong commit- ment to ensuring patient safety. In 1989, she wrote,

Jean’s concern for the protec-

Perioperative nurses must be permitted to establish safe levels ofpatient cafe in

terms of nursing capabili- ties and institutional staflng limitations. They must be able to withstand outside pressure to compromise the quality of care given to patients in suvger7, in order to get the job done.’

She was among the first to rec- ognize the importance of main- taining patient safety in a high- risk environment while placing the patient’s preferences and desires first. Her dedication to this premise later led to the formation

of AORN’s Special Committee on Ethics.4

AN AORN LEADER Jean’s focus on patient safety

became even more apparent dur- ing her AORN presidency. Her monthly “President’s Message” columns are evidence of her belief that nurses should be involved in health care improve- ment activities. She was instm- mental in moving forward AOR”s goal to “participate in effectiveness and outcome of health care initiatives.”’ During her leadership years at AORN, Jean supported activities that helped develop a blueprint for action related to effectiveness ini- tiatives. This blueprint continues to serve AORN. Her support of these types of activities led to the work that evolved into what now is known as the Perioperative Nursing Data Set. These efforts and others promote the under- standing of the relationship between nursing contributions and patient outcomes in perioper- ative settings.

In 1992, just before AORN’s annual Congress, Jean wrote,

When will it change? Images that people have about individuals involved with health care in our county-nurses, physi- cians, administrators, health care regulators, insurers, attorneys, and anyone else remotely con- nected with “the system’:

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Page 2: Lessons about patient safety from Jean Reeder

AUGUST 2002, VOL 76, NO 2

continue to be dismal.6

Those of us who knew her recog- nize the writing in this “Presi- dent’s Message” as Jean’s dis- tressed reaction to the information presented in The Great White Lie: How America k Hospitals Betray our T m t and Endanger our Lives.’ How anguishing this book must have been to an individual so committed to protecting patients. In this message, she also wrote about the terrible tragedies related to medication errors, equipment malhctions, over- worked nurses, incompetent sur- geons, and poorly trained staff members. Rereading this “President’s Message” 10 years later, one is forced to question whether anything has changed in our health care system.

Jean’s reaction to this book must have precipitated her renewed commitment to patient safety and her work in subsequent years. She wrote,

I believe thatfidelity, the commitment, begins with each of us. Attaining and maintaining competence is one of the primary respon- sibilities that we have as professional nurses.

She continued to explain.

It means having the courage to say that they [nurses in clinical settings] have not used a particular piece of equipment before and need some instruction before they can competent- ly participate in the procedure. Nurses protect patients j-om harm and injury by following recommended practices

and reporting unsafe occurrences.

A SENTINEL EVENT Jean’s career after leaving the

military led her to a position as chief of nursing. In this role, she advocated for ethical nursing practice. She also served as an active member of numerous nurs- ing organizations and as a consult- ant. During this time, she made presentations to groups such as the American College of Surgeons’ committee on operating room environment and the World Congress of Operating Room Nursing. Jean was one of those unique professionals who could not only Yak the talk” but “walk the walk” in every aspect of her professional career.

In 1998, there was a medical error resulting in a child‘s death in the facility where Jean was employed. She told the nurses involved that she was concerned about how the incident and subse- quent investigation were affecting them, but she also told them that it was her responsibility to assess their nursing practice and that they, together, had to do the right thing for the family. She lived by her belief that nurses are responsi- ble and accountable as profession- als for the nursing decisions they make and actions they take.”

fully at the time of Jean’s death. Until she died, Jean continued to believe that the nurses involved did not inflict intentional harm on the patient. She said that systems issues contributed to the event, mistakes were made, and the family deserved better.” Jean rec- ognized the organizational, pro- fessional, and personal conse- quences of sentinel events and strove to help others learn &om

This incident was not resolved

this particular event. She did not want anyone to make the same or a similar error. The death of this young child deeply affected Jean. Those who knew her best had a sense of how much this influ- enced Jean’s life and her subse- quent efforts related to patient safety.

A CONSULTANT After this sentinel event, Jean

left the health care facility and started a consulting business pri- marily focused on patient safety issues. She wrote and spoke extensively on the topic and became a renowned perioperative patient safety expert. She present- ed at numerous AORN Con- gresses, spoke at many chapter events, and discussed her work at scholarly meetings. When an AORN staff member had a ques- tion about patient safety, Jean’s expertise contributed to and guid- ed many organizational efforts.

Jean’s expertise touched every aspect of patient safety. She understood human factors research and could explain it so others could understand. She understood the culture of safety and the ethical imperative for patient safety and system errors. She could apply complex theoreti- cal concepts to clinical practice and make them come to life for clinicians. Jean wrote and spoke extensively about supporting health care professionals involved in medical errors. She taught us that although no health care pro- fessional intends to harm patients, errors can OCCUT.’~ She told us that

expressions of genuine con- cern and care can give bealth care professionals involved in an error] strength and courage to

319 AORN JOURNAL

Page 3: Lessons about patient safety from Jean Reeder

AUGUST 2002, VOL 76, NO 2

cope with whatever lies ahead. I’

She cautioned us that if we do not want to lose “experienced, knowl- edgeable health care professionals who make an error” we must “develop ways to reduce the opportunity for

CONCLUSlON Jean’s core beliefs and values

were the basis for her nursing practice, and they should be con- sidered guiding principles in today’s health care environment. Jean’s values were, in her own words,

accountability-being answer- able for the things one does and the decisions one makes; advocacy-supporting impor- tant causes actively; caring-expressing concern

about others and their welfare; fidelity-keeping promises and remaining faithful to one’s commitments; justice-treating people equal- ly and with fairness; respect-showing respect for the patient, his or her family members, other nurses, and the governing board process; and veracity-telling the truth.I5 Jean’s gifts and lessons in her

life, work, writings, and humanity will guide AOR”s patient safety initiatives well into the twenty- first century. She helped create a commitment to patient safety and ethical care in many of us who are left behind to carry on her work and efforts. Those of us who had the privilege to know her and work with her on patient safety issues always will miss her.

We always will be grateful for the lessons and writings she left behind. Her courage and unfailing commitment to this cause will help us in our efforts. Thank you Jean-we will m i s s you and all that you gave us. Please know that your work guides us in our efforts to ensure that every patient receives safe, competent care. Together, we can make this dream a reality.

SUZANNE C. BEYEA

AORN DIRECTOR OF RESEARCH RN, PHD

AILEEN R. KILLEN RN, PHD, CNOR

ON PATIENT SAFETY PRESIDENTIAL COMMISSION

JACKIE 1. BERLANDI RN, MS, CNOR EDITORIAL BOARD

NOTES 1. J M Reeder, “Help your disabled patient be more

independent,” Nursing 14 (November 1984) 43; J M Reeder, S Puterbaugh, “Issues in perioperative nursing prac- tice, part 3,” AORN Journal 36 (November 1982) 827-840; J M Reeder, “Ethical dilemmas in perioperative nursing practice,” Nursing Clinics of North America 24 (December 1989) 999-1007.

practice,” 999-1007. 2. Reeder, “Ethical dilemmas in perioperative nursing

3. Ibid. 4. J M Reeder, “AORN members can assist new com-

mittee with identifying ethical issues,” (President’s Message) AORNJournal54 (July 1991) 8-10.

tiveness initiative needs the support of all its members,” (President’s Message) AORN Journal 53 (June 1991)

5. J M Reeder, “A0R”s commitment to the effec-

1346-1348.

6. J M Reeder, “Fidelity, nursing, and ‘the great white lie,”’ (President’s Message) AORN Journal 55 (March 1992) 700-702.

7. W Bogdanich, The Great White Lie: How America S Hospitals Betray Our Trust and Endanger Our Lives (New York Simon & Schuster, 1991).

8. Reeder, “Fidelity, nursing, and ‘the great white lie,”’ (President’s Message) 700-702.

9. Ibid. 10. J M Reeder, personal papers, 2001. 11. Ibid. 12. J M Reeder, “Being there supporting health profes-

sionals involved in medical errors,” SSM 7 (October 2001) 40-44.

13. Ibid. 14. Ibid. 15. Reeder, “Fidelity, nursing, and ‘the great white

lie,”’ (President’s Message) 700-702.

321 AORN JOURNAL