"I told him to wear gloves, but he did not listen" - The limits of patient awareness in ensuring quality and safety of care
For the last two years, together with my colleagues, I have been supporting activities in Africa and in Asia focused on improving safe injection practices and ensuring that every injection is given with a new unused syringe and needle in a sterile manner and that patients don’t receive injections unnecessarily where other simpler, safer options are feasible.
Two incidents within my own family brought these problems too close to home.
Last year, while I was based at the project headquarters in Bethesda and my parents were in New Delhi, India, I received a call from my mother informing me that my father had been feeling weak and they had gone to the local clinic where they had given him a ‘glucose drip’ for energy. Duh! Here I am preaching to the world not to use ‘glucose drip’ for ‘energy’ and here is my father receiving an unnecessary IV infusion! Adding insult to injury, my mother tells me that the doctor has left the IV cannula in place overnight so that my father could return to receive another ‘glucose drip’ the next day!
I managed to convince my parents to go back to the clinic and have the cannula removed and that the glucose drip would not help my father. It later turned out that his weakness was due to the lingering after effects of a viral infection and he is back to his energetic, lively self now.
Fast forward to 2013, I am now based in New Delhi and living with my parents. My parents had their annual physical and needed their blood drawn for tests, so my mother had arranged for the laboratory technician to come home to draw the blood for the tests. The next morning, I woke up bleary eyed from my jet lag and happened to walk into the living room when the laboratory technician was almost finishing up drawing blood.
Guess what - he was not wearing gloves! I was almost speechless. At times like this, a wise person would count to ten before speaking, but alas I am not so wise. I reprimanded him, but halfway through my speech, he packed up and left in a rush. I wondered how my mother could overlook such blatant breaches of infection control since she is quite conversant with infection control by now, thanks to my repeated badgering and her own innate sense of doing things properly.
Further conversation with Mom revealed that she had taken substantial steps to ensure adequate infection control:
- The previous day when she was fixing the appointment with the lab, she had specifically told them to make sure the technician has gloves when he comes to draw blood.
- She clearly told him to wear gloves before he started, but he said, ‘These are vacutainers, they are new and no gloves are needed for this.’ She presumed since he is the professional he may know better and did not argue further.
- She also told him to wash his hands; a request which he simply ignored. So, not only did he not wear gloves for an intravenous procedure, he also did not wash his hands before or after the procedure despite being asked to do so.
My mother is a well informed, well-educated citizen, and she did her part by taking all the steps mentioned above, but to no avail. A patient will never know enough about health care procedures to confront a health practitioner, especially in scenarios such as this where the healthcare professional blatantly lied instead of listening to the patient. Also, the patient is in a vulnerable position and may not be in a situation to stop a procedure when they have doubts about its safety; if they choose to postpone a procedure, a delayed test result may mean delayed treatment and prolonged suffering. There is also the fear that if one confronts a health care practitioner, the doctor or nurse will not take adequate care of them after that. I think we expect too much if we put the responsibility solely on the patient to ensure that they get safe health care.
One of the solutions advocated in places where syringe and needle reuse is prevalent is to tell patients to get their own syringes and needles. Injection reuse was not the problem my mother faced – it was infection control. My mother asked me, “I did my best in this case and still they don’t listen, so what should I do next time?” I immediately said, “Mom, if they don’t listen you should just keep gloves and alcohol hand rub available next time you have blood drawn at home.” But now I wonder: Where does this end? Maybe the technician should just come empty handed and the patient should provide him with all the supplies and instructions! How much onus can we place on the patient for safe care? How vigilant can we expect a patient to be when they are already sick and have so many things to deal with?
The other issue raised by this incident is the accreditation standards in India. The website of the laboratory network flaunts its various accreditations and its commitment to quality. It states that it is accredited by the “National Accreditation Board of Testing and Calibration Laboratories” and conducts regular quality audits and staff training. But, if a laboratory cannot ensure that blood draws – the very bread and butter of a laboratory service – are done safely, then I question the creditability of the accreditation procedures of the National Accreditation Board of India.
Yes, we should educate people about their rights and about safety and quality issues and teach them to advocate for themselves. The confontation was not entirely in vain; the next time the phlebotomist came to our house, he came prepared with gloves and alcohol hand rub. Patient and citizen involvement is critical to the safety and quality movement globally. But given that the patient will rarely have the same level of technical knowledge as a health care professional, the ultimate onus of health care safety and quality has to be institutional. It has to be mandated by the government, and it has to be rigorously implemented by all health care institutions and professionals, regardless of whether the patient speaks up or not.