(Licensed Vocational Nurse)

This is how medicine handles the worst moments for patient safety

The sociologist Robert Merton talked about “goal displacement,” the process by which the original goal of a bureaucracy becomes displaced by the goal of protecting itself. The ubiquity of this in medicine is not adequately recognized for how it pushes patient safety lower on the list of priorities.

Cases like this and Dr. Vikas Kashyap are examples of the adinistrators running medicine having priorities that are more important to them than the safety of their patients. They don’t believe they do and take umbrage at that suggestion, but look at their behavior. If they the safety of patients was their first priority wouldn’t they protect them from serial killers? The fact that some of the most prolific serial killers in history have worked in medicine is not the “one-off” they rationalize them as being.

In February 1983, a grand jury began to look into 47 suspicious deaths of children at Bexar County Medical Center Hospital in Texas. All of the deaths had occurred during the four years that Genene Ann Jones had been a nurse there. A second grand jury was organized to cover the children in a second clinic as well, the one where Genene Ann Jones went to work after she left Bexar County Medical Center. Jones had worked in several healthcare facilities in Texas prior to these two, but the investigations were confined to the two most recent.

At Bexar County Medical Center there had been sufficient grounds to dismiss Genene Ann Jones several times over, but the head nurse protected her. It was clear to everyone around Genene Ann Jones that children were dying in her unit from problems that shouldn’t have been fatal. And it was clear that they were dying only when she was around. Some of the staff called her shift the Death Shift.

When a doctor finally stepped forward to tell the hospital that Genene Ann Jones was killing children her supervisor protected her. Other nurses tried to bring her actions to light, but it is rare for anyone in medicine to take such concerns anywhere other than to supervisors.

There needs to be a scrutiny by someone outside of medicine. Inside medicine careers depend on protecting themselves and their colleagues and their institutions rather than patients.

Like perhaps a state patients board

Since the hospital did not want bad publicity, they accepted whatever the head nurse said as though it were fact and did nothing other than to fire a nurse who reported the problem – a normal response (see Loyalty, for instance). When a committee finally was formed to look into the problem, they handled the problem (in their eyes) through a general administrative action.

They did not single out the specific problem operator. In medicine they avoid that at all costs. That disinclination offers yet another layer of protection to problem operators. The committee, instead, addressed the situation though a general administrative action that upgraded the level of education needed to work in that unit.

Genene Ann Jones was only a licensed vocational nurse (LVN) which meant she did not have as much education as a registered nurse (RN). The administrative action of the committee ordered that from now on to work in that facility a worker would have to be an RN. In that way they quietly were able to slip Genene Ann Jones out of their facility without pointing her out as the problem, and without creating any record or taking any action that would indicate that there ever had been a problem in their facility.

They wanted to have an unblemished reputation. They wanted that than they wanted to protect future children from a serial killer. So they didn’t call the police. They didn’t warn anyone about her. Nothing was done to prevent her from murdering children someplace else. So Genene Ann Jones got a job in another facility and resumed murdering children there.

The Wellbeing of Patients is their First Priority, Right?

We know about this case only because of how large the scale of it was. Predators operating on a smaller scale, or with stronger social skills, can have long careers in medicine.

Genene Ann Jones already had worked in several facilities before coming to Bexar County Medical Center Hospital without anything coming to light, and none of them prevented her from resuming her practice somewhere else. None of previous facilities did anything that would lead us to believe that keeping patients alive is as important to them as keeping their reputations unblemished. If the administrative committees at those other hospitals never discussed it, then personnel on a lower level got her out of their hair without telling them about it. Either way, the people in medicine who dealt with her had priorities that were more important to them than keeping her from murdering more patients.

Chronic One-offs

Medicine dismisses such examples as “one-offs.” Medicine refuses to understand these examples as windows on how medicine in general responds to patient safety problems. If you want to see how a system functions, look at how it handles its worst moments. In medicine, the inertia against reporting and against incurring liabilities is so great that they don’t even protect patients from serial killers, not even when the patients are children. The only thing approaching being unique, or a “one-off”, about this case is it’s scale. The rest is a mirror of many other cases and many other problems and how medicine responds to patient safety problems in general. Its scale is only what brought it, and some of the other serial killers in medicine, to light.

One of the problems is Robert Merton’s “goal displacement,” the original goal of a bureaucracy becoming less important than protecting itself. There are additional ones, like simple narcissism, as covered in Medical Errors and Medical Narcissism, by John Banja, PhD. (links to a page on this site) that discusses the psychological reactions among caregivers that compromise integrity and ethics. There also is the exploitation and violation of patients, subjects rarely mentioned in patient safety circles.

The patient safety movement spends its time looking at symptoms of the problem, like errors in medication, rather than the underlying causes for why the system has such problems in the first place and why it has operators like Genene Ann Jones preying on patients for so long without anyone protecting patients from her. Safety cannot be achieved without reporting and consequences (which is what was meant by <truth/justice/patient safety> the logo that used to be at the top of every page of this site – it’s a path). I doubt we ever can get that from healthcare professionals. Look at how their personnel and their system responded in this situation.

It is not in the interests of the caregiving community to make patients safe. The patient safety movement needs to be run by people for whom it is.