Cases & Commentaries

Do Me a Favor

Commentary By Ann Williamson, PhD, RN

The Case

A 26-year-old gravida 4 para 1 woman reported
that her last menstrual period was 5 weeks prior, and she had a
positive home pregnancy test. With a history of one ectopic
pregnancy, one normal vaginal delivery, and one spontaneous
abortion (miscarriage) at 6 weeks, she was concerned about a repeat
ectopic pregnancy. The patient was a nurse who worked at the
hospital and was friends with one of the obstetrics/gynecology
residents. She asked the resident to perform a transvaginal
ultrasound to check for an intrauterine pregnancy and rule out an
ectopic pregnancy.

The resident brought the patient into the
antenatal testing room without notifying the nursing staff or
registering the patient. A transvaginal ultrasound was done, which
did find an intrauterine pregnancy; neither the findings nor the
patient's condition was documented in the medical record. The
vaginal probe was not cleaned appropriately after the
procedure.

The charge nurse on the floor noticed that the
bed in the antenatal testing room had been used. On inquiry, she
could not find a patient who had been admitted to that room.
Ultimately, she asked the resident, who revealed that he had
scanned his friend.

The Commentary

This case describes a common scenario among
health care professionals. At some point, most of us have been
asked to help a colleague, friend, or family member with a medical
concern, or ourselves asked a colleague for advice about our own
health or that of a family member. No doubt, some will read this
case, scratch their heads, and wonder what the problem is, exactly.
Is this just a case of an overzealous charge nurse upset with two
colleagues who violated "protocol" and failed to clean up after
themselves? Aside from that, what patient safety lessons are
embedded in this case?

Although informal caregiving among health care
providers is likely common, a literature search revealed no
published reports on such informal care. However, some literature
touches on the related issue of physicians caring for family
members. A 1991 survey found that 99% (n=461) of physicians
reported being asked to provide medical advice, diagnosis, or
treatment to family members, with up to 83% doing so.(1) Another
survey, focused on physicians treating their own children, found
that nearly three in four reported providing treatment for afebrile
illnesses.(2) Finally,
another study found that 85% of medical and family practice
residents had written a prescription for someone who was not their
patient; virtually none were aware of federal and state regulations
prohibiting the practice.(3)

Informal polling of front-line staff at an
academic medical center about requests for advice/treatment by
colleagues suggests that scenarios similar to this case study are
commonplace. Among the many personal anecdotes: nurses revealed
that physicians often ask them for analgesics, antibiotics, or
other medications to get them through busy shifts when they are
feeling ill. In turn, physicians tell of frequent requests for
prescriptions by non-patient colleagues. Both doctors and nurses
recounted professional requests for health care "favors" include
taking blood pressures, checking blood glucose levels, performing
phlebotomy, administering intravenous infusions, and performing
electrocardiographs, to name a few. Justifications for such
requests include long work hours, difficulty accessing care when
off-duty, distrust of or distaste for the "bureaucratic" system
(providers frequently confessed that they did not have a primary
physician and preferred to be treated by someone they know),
reluctance to seek care through formal channels for minor problems,
and efficiency/convenience. Since no apparent difficulties usually
arise, the provider culture has come to "normalize" these informal
practices.(4-6) The effect
of this is to remove any possible professional stigma from seeking
or providing care in this underground system, and to render any
errors that do occur relatively invisible.

The American Medical Association Code of Ethics
suggests that, in general, physicians should avoid treating
themselves or members of their immediate families, with the
exception of routine care for minor short-term problems.(7) The American
College of Physicians Ethics Manual also suggests that physicians
exercise caution if they choose to treat themselves, family
members, close friends, or closely associated employees.(8,9) These
sources focus on issues related to autonomy, confidentiality, and
liability, but do not fully address safety risks inherent in
informal caregiving among colleagues (Table).(7,9-11)

Why might informal care be potentially unsafe?
There are several reasons. Informal care may bypass standard
routines, safety checks, and supervision. In this case, the
resident may not have been fully competent to perform the exam
(resulting in injury or misdiagnosis), but reluctant to reveal this
to his colleague. He was unsupervised and unchaperoned, which is
problematic given the intimate nature of the procedure.(12) The exam
may have provided the patient with a false sense of security. She
was not afforded the usual pre- and post-procedure routines, such
as education, resulting in potential delays in seeking follow-up
treatment or future worries (eg, if the patient miscarried this
pregnancy, she might mistakenly attribute it to the exam). The
vaginal probe may not have been properly cleaned prior to use,
exposing the patient to potential infection risks.

In this case, an important quality of care and
safety component was bypassed: the involvement of other appropriate
team members. A transvaginal ultrasound is a relatively reliable
and low-risk procedure at this stage of pregnancy; nevertheless,
the risk for misdiagnosis exists (13,14) and
appropriate senior resident or attending supervision would reduce
this risk. Additionally, failing to include nursing in procedures
exposes patients to risks of injury related to inadequate
analgesia, inattention to other procedural details, and potential
delays in emergency response, if complications arise. In addition,
it deprives the patient of concomitant social and psychological
support.

When informal care occurs, another potential
safety issue is the failure to document care or follow protocols.
Patients undergoing procedures should be registered, and care
should be documented for future reference. Breach of this common
standard, as happened here, means that future providers will not
have the benefit of the information gleaned from this exam.
Appropriate protocols, including review of the case with another
physician, were circumvented. Furthermore, failure to document care
exposes the provider to legal liability.(15)

This case also illustrates a failure to return
the system to "ready" status and to adhere to appropriate infection
control principles. The colleagues left the vaginal probe and the
room in a state of disarray, creating risks for future patients,
including potential delays in treatment and/or infection.
Maintaining equipment and supplies in "ready" status is critical
for systems responsiveness.

Institutions need to create formal policies
related to care of colleagues and family. While advice about
routine problems, referrals, or simple prescriptions could be
considered appropriate, policies should target intimate, invasive,
or complex diagnostic work-ups, treatments, or procedures. An
effective policy would not prohibit a care provider from
facilitating the care of a colleague or family member, but rather
would channel it through the formal systems, which have been
carefully developed to provide safe and effective care. In this
case, the resident could have done the procedure quickly, but
should have had the patient formally registered, staffed by an
attending, as well as chaperoned and assisted by nursing.

Systems approaches to prevent this type of error
in the future center on the "safety culture."(4,6)
Open discussions about appropriate types of caregiving among
colleagues in institutions is a good first step, followed by
enforcement of agreed-upon standards. Additionally, educating all
providers about the potential risks and liabilities of informal
caregiving among colleagues might be helpful. One hopes that the
charge nurse discovering this error capitalized on the opportunity
to initiate dialogue about setting standards for such behavior in
the future.

Key Considerations for Safe Caregiving
Among Colleagues (9-11,15)

  • Consider carefully the potential risks
    associated with informal treatment prior to making or responding to
    requests of colleagues for medical treatment. Assume that obtaining
    a complete history/exam may be difficult owing to privacy concerns
    of the colleague.
  • Restrict treatment to advice for minor
    or routine concerns, as much as possible, avoid the use of
    institutional resources, intimate/invasive procedures, and complex
    decision-making.
  • Assess carefully your level of
    knowledge, skill, and competency to manage the problem. Resist the
    temptation to practice outside your specialty or beyond your level
    of expertise.
  • If you choose to treat a colleague, it
    is wise to document the encounter and provide the same level of
    care and consideration that you would for any patient. Why not
    offer to see the colleague in your clinic/office (and facilitate
    that)—instead of risking the hurried hallway encounter?
  • Remember to consider the need for
    follow-up, education, and support. Communicate with other care
    providers, as appropriate, to ensure these needs are met.
  • Organizations should consider developing
    explicit guidelines regarding informal caregiving among
    colleagues.

Ann Williamson, RN,
PhD
Associate Clinical Professor, UCSF School of Nursing
Patient Care Director, Adult General Clinical & Emergency
Services
UCSF Medical Center

Acknowledgment: The author wishes to thank
Michael Fox, RN; Sarah Pearce, RN; Audrey Lyndon, MS, RN; Christina
Atwood, MPH; and the UCSF Medical Center RN Patient Safety
Fellows.

References

1. La Puma J, Stocking CB, La Voie D, Darling C.
When physicians treat members of their own families. Practices in a
community hospital. N Engl J Med. 1991;325:1290-4.[ go to PubMed ]

2. Dusdieker LB, Murph JR, Murph WE, Dungy CI.
Physicians treating their own children. Am J Dis Child.
1993;147:146-9.[ go to PubMed ]

3. Aboff BM, Collier VU, Farber NJ, Ehrenthal DB.
Residents' prescription writing for nonpatients. JAMA.
2002;288:381-5.[ go to PubMed ]

4. Reason J. Managing the risks of organizational
accidents. Burlington, VT: Ashgate Publishing Company; 1997.

5. Vaughn D. The challenger launch decision.
Chicago, IL: Chicago University Press; 1996.

6. Pizzi LT, Goldfarb NI, Nash DB. Promoting a
culture of safety. In: Shojania KG, Duncan BW, McDonald KM, Wachter
RM, eds. Making health care safer: a critical analysis of patient
safety practices. Rockville, MD: Agency for Healthcare Research and
Quality; 2001: 447-457. AHRQ publication 01-E058. Evidence
report/technology assessment. no. 43. Available at:
[ go to related site ]. Accessed April 19, 2004.

7. Self-treatment or treatment of immediate
family members. American Medical Association Web site. Available
at:
[ go to related site ]. Accessed April 19,
2004.

8. Ethics manual. Fourth edition. American
College of Physicians. Ann Intern Med. 1998;128:576-94.[ go to PubMed ]

9. Ethics case study: should doctors treat their
relatives? ACP Observer. American College of Physicians Web site.
Available at:
[ go to related site ]. Accessed April 19, 2004.

10. La Puma J, Priest ER. Is there a doctor in
the house? An analysis of the practice of physicians treating their
own families. JAMA. 1992;267:1810-2.[ go to PubMed ]

11. Schneck SA. "Doctoring" doctors and their
families. JAMA. 1998;280:2039-42.[ go to PubMed ]

12. Ehrenthal DB, Farber NJ, Collier VU, Aboff
BM. Chaperone use by residents during pelvic, breast, testicular,
and rectal exams. J Gen Intern Med. 2000;15:573-6.[ go to PubMed ]

13. Condous G, Okara E, Bourne T. The
conservative management of early pregnancy complications: a review
of the literature. Ultrasound Obstet Gynecol. 2003;22:420-30.[ go to PubMed ]

14. Yip SK, Sahota D, Cheung LP, Lam P, Haines
CJ, Chung TK. Accuracy of clinical diagnostic methods of threatened
abortion. Gynecol Obstet Invest. 2003;56:38-42.[ go to PubMed ]

15. Johnson LJ. The risk of treating friends and
family. Med Econ. 2003;80:72.[ go to PubMed ]

Table

Table. Safety and Quality of Care Risks of
Informal Caregiving Among Colleagues

Reluctance to obtain or provide a
complete medical history

Reluctance to obtain or submit to a
complete medical examination

Diagnosis and treatment beyond provider
specialty knowledge, expertise, or competency

Loss of patient privacy and
confidentiality

Lack of objectivity on the part of
patient or provider

Under- or over-treatment related to
"wishful thinking," hurried/informal nature of encounter,
hypervigilance, or other factors

Circumvention of systems safety
checks

Circumvention of beneficial education
and/or procedural protocols

Impaired or inadequate patient
education

Lack of documentation

Inadequate or absent follow-up