A rant about safety

How hard can it be to make sure you’re doing the right procedure on the right patient? You’d think this would be supremely basic, but apparently – in spite of all the emphasis on patient safety and the establishment of time-outs and other protocols – it remains beyond the grasp of many medical teams.

There was depressing news from Colorado recently. In a study published last month in the Archives of Surgery, 25 wrong-patient procedures and 107 wrong-site procedures were performed over six years, from the beginning of 2002 to mid-2008. These were not minor “oops” events. In five of the procedures done on the wrong patient and 38 of the procedures done on the wrong site, significant harm resulted to the patient, the study’s authors reported. In one case, a patient died.

Wait, there’s more: Last week the New England Journal of Medicine came out with another study, this time from North Carolina, that found harm to hospitalized patients was common and, as the authors delicately put it, there was “little evidence of widespread improvement.” Although most of the reported harms were temporary and/or treatable, 2.4 percent caused or contributed to the patient’s death.

And here in Minnesota, the first state to require hospitals and surgery centers to report adverse events, there’s been little significant improvement. Although fewer serious fall-related injuries took place in 2009, the number of wrong-site surgeries actually went up from the previous year. There was virtually no change in the incidence of retained foreign objects after surgery or the incidence of serious pressure ulcers.

We might have expected to see these kinds of statistics 15 years ago, when medical harm was rarely discussed openly and few, if any, systems were in place to help ensure safer practices. But not in 2010. I mean, come on. It’s been more than a decade since the publication of the Institute of Medicine’s landmark report on medical error, “To Err Is Human,” blew open the doors on the bad things that often befall patients and sparked a nationwide patient safety movement.

It’s disappointing and dismaying.

To be sure, patient care is complicated. It takes relentless focus and hard work to get it right. Dr. Bob Wachter, one of the smartest and most knowledgeable authorities in the U.S. about patient safety, offers this assessment:

Lots of good people and institutions have spent countless hours and dollars trying to improve safety. Why isn’t it working better?

I think the study tells us something we’ve already figured out: that improving safety is damn hard. Sure, we can ask patients their names before an invasive procedure, or require a time out before surgery. But we’re coming to understand that to make a real, enduring difference in safety, we have to transform the culture of our healthcare world – to get providers to develop new ways of talking to each other and new instincts when they spot errors and unsafe conditions.

Dr. Wachter has nailed one of the most difficult and elusive elements in patient safety: the culture of health care. On the one hand, the mandate is “First, do no harm.” But on the other hand, there’s often a tacit belief that harm is the price patients sometimes must pay for medical intervention.

How else to explain the stubborn persistence of serious and grievous errors? Here’s just one example: Vincristine, a drug used for treating several different types of cancer, is toxic to the central nervous system and should only be given intravenously. If it’s injected into the spine, it causes paralysis, coma and usually death. It’s not a pleasant way for a patient to die and it’s not pleasant to observe either.

This is not a rare or novel drug. It has been in use for more than 40 years and its inclusion is standard in many chemotherapy regimens. The risks of injecting vincristine into the spine are well known among cancer specialists. The damage is almost always irreversible and the vast majority of victims die. Yet despite this knowledge, despite warnings printed on the package overwrap, despite a myriad of safety recommendations, tragic mistakes continue to happen. From 2001 to 2005, there were two reported cases in the United States of vincristine being accidentally injected into the patient’s spine. There were five instances in Europe and one in Australia. Every single one of these patients died – and these are just the cases we know about.

You could argue that patients who undergo cancer treatment should understand and accept the risks that accompany chemotherapy. But I’m dead certain that being paralyzed by a preventable error involving vincristine is not, by most patients’ standards, part of this bargain.

It’s one thing to talk about the importance of safety. It’s quite another thing to actually internalize it and to integrate it in every process in the health care organization. One of Dr. Wachter’s commenters puts it very bluntly: Many providers don’t take safety seriously enough. She writes, “We have to build a generation that truly believes from the bottom of their hearts ‘that just because medical errors happen does not mean they must happen!'”

Here’s more from Dr. Wachter:

Organizations need to learn the right mix of sharing stories and sharing data. They need to embrace evidence-based improvement practices, while being skeptical of practices that seem like good ideas but haven’t been fully tested. And policymakers and payers need to create an environment that promotes all of this work – policies that don’t tolerate the status quo but steer clear of overly burdensome regulations that strangle innovation and enthusiasm.

Are we ever going to eliminate medical harm? The answer is no. Medicine is complex and every patient and every situation is to some degree unique. Perfection is neither possible nor realistic. Too often, however, health care is faulty and error-prone, and too many within the industry accept this as a necessary evil rather than striving for improvement. I can only wonder why the public hasn’t risen up in collective outrage and demanded better.

West Central Tribune file photo

Healthy Area Voices

There are currently more than 2,000 blogs in the Area Voices community, including about 30 that are health-oriented. Many of these are recent additions to the blogosphere and it’s time they were introduced to readers.

I’m going to start with one of the newest local blogs, the Kandiyohi County Drug-Free Communities Coalition. This blog was launched by the coalition to share information about its mission and activities and to educate the community about issues ranging from tobacco use to underage drinking. One of the most recent posts takes a look at FDA action to outlaw the chemicals used for making synthetic marijuana, also known as K2. There’s also an entry about Four Loko, the new high-octane energy drink that is drawing safety scrutiny and has already been banned on several college campuses.

The things kids do at vaccination clinics! Douglas County Public Health shares some cute stories on their new blog, Health Out Loud. The blog is co-authored by three public health educators and promises to be “an online destination to connect with your local public health department.”

I’m impressed by To Be Well, a blog started last month by Dr. Connie Morrison, a surgeon with the Avera Worthington Specialty Clinic in Worthington. It’s thoughtful and informative, featuring entries on topics such as Alzheimer’s disease and the stress-gives-you-stomach-ulcers myth. Dr. Morrison also has added several topic pages and health news RSS feeds, making this blog a resource for readers to visit often.

Fairview Red Wing Medical Center recently started health notes, a blog dedicated to health information that’s relevant and easy for consumers to understand. They’ve tapped their staff’s expertise for producing the entries, giving the reader a diversity of posts on yoga, whooping cough and Halloween costume safety.

Here’s another public health blog: Fargo Cass Public Health. They’re using the blog format to help let the public know about resources such as tobacco prevention education materials and flu vaccination clinics. They’ve also posted some good safety information, such as this entry about passenger vans.

Allen Anderson, a registered dietitian with the Grand Forks (N.D.) Public Health Department, is the blogger behind Grand Forks Nutrition and Health, which takes a look at nutrition, physical activity and health. I especially like the advice he offers about navigating the grocery store and planning “super suppers.”

That’s a sample of some of the health-related blogs to be found at Area Voices. Readers are invited to bookmark them and check back often for new entries.

If you’re thinking about starting a health blog (or any other type of blog, for that matter), what are you waiting for? It takes only a minute to set up a free account with Area Voices. There’s plenty of technical support available from Forum Communications Company, including free weekly webinars that give bloggers a chance to talk directly with the tech support crew. Just do it!

Defining quality care

A couple of readers let me know offline that they disagreed with a post last week examining the implications of Minnesota’s newly released quality performance scores for clinics and hospitals. Their objections can be summarized as: “Why are you anti-measurement and anti-consumer?”

For the record, I am neither. Performance measurement is a valuable tool to help providers know how they’re doing. Without it, there’s no way to objectively know whether they’re truly delivering the best evidence-based care or whether they just think they are. Consumers also deserve to know how their provider stacks up against the standard of care. If nothing else, embarrassment over the public reporting of less-than-stellar scores can be a spur for providers to try to improve.

We shouldn’t be misled, however, into thinking that percentages on selected measures are the sole way to gauge whether a provider offers quality care. It’s critical to keep in mind that performance scores represent only some of the activities that take place daily in Minnesota clinics and hospitals. It’s also critical to remember that they’re based on a sample of patient data, and don’t represent every patient encounter.

If performance scores aren’t the whole story, then what is? I’m not sure there’s any universally accepted definition of what constitutes quality hospital or outpatient care. To some extent, quality is in the eye of the beholder. But to borrow Justice Potter Stewart’s famous definition of pornography, I know quality when I see it.

These are some of the things I would want to see in a quality provider (and readers are invited to add their own in the comment section):

– A culture of excellence for every process that touches the patient.

– A commitment to recruiting and hiring good people and giving them ongoing training and support.

– The ability to think in terms of systems rather than silos.

– Knowledge of the community in which they practice and the populations they serve.

– Recognition that patients are individuals and cannot be reduced to labels or cookbook medicine.

– Rigorous attention to patient safety and to examining and improving processes to reduce the likelihood of error.

– Accountability for errors, both for close calls and for actual harm to patients.

– Responsive to emerging needs and issues.

– Up to date in knowledge.

- Purposeful in seeking feedback from patients and finding ways to engage them in ongoing dialogue about the patient experience and how to make it better.

– Willing to be a partner with other community organizations.

- Innovative in finding new ways to meet patient and community needs.

– Good stewards of resources who are careful about unnecessary treatment and make wise decisions about investing in technology and new services.

It’s extremely difficult, perhaps even impossible, to quantify and measure these things, yet they’re vitally important to delivering good care. And therein lies the issue with performance scores: When numerical scores are touted as the measure of whether a provider is good, it can downplay or ignore other critical factors in favor of sheer numbers and statistics. And when this happens, the risk is that quality will ultimately be reduced to the things we can objectively measure, never mind all the rest of it. Is this seriously what we want for health care? I think you know how I would answer that question.

HealthBeat photo by Anne Polta

The patient experience

Do hospital executives care whether patients have a good experience in the hospital? The answer, according to a recently released HealthLeaders Media survey, is that they do.

But it might not always be evident because efforts to enhance what’s known as “the patient experience” often fall short, the survey found. The subtitle of the report says it all: “When it comes to patient experience, executives are enthusiastic, ambivalent and a little clueless.”


More than 200 top-level hospital executives responded to the survey, which attempts to identify what hospitals are doing to increase patient satisfaction and the obstacles that are getting in their way.

One of the most interesting findings of the survey is the importance that hospital leaders place on giving patients a high-quality experience:

Nearly 90% of the top-level healthcare executives said that patient experience is either their top priority (33.5%) or among their top five priorities (54.5%). And when we asked them about their priorities five years from now, even more made it their No. 1 pick. Forty-five percent predicted that patient experience would be a top priority in five years; another 50.5% said it would be in their top five.

The number of respondents who said patient experience would not be a priority at all in five years? Zero.

One of the most discouraging findings, alas, is that what the executives are saying and what they’re actually doing are two different things.

Consider: The majority have a budget of less than $50,000 this year for initiatives to improve the patient experience. Eleven percent had no budget at all for these initiatives. Many of the respondents seemed unclear on whose responsibility it is to lead patient-experience initiatives; fully one-fifth said no one at their hospital was in charge of this. Other issues that were cited included a lack of buy-in by the employees and a lack of an overall plan.

What’s more, there seemed to be little innovation. Most of the survey participants said they observe and adopt best practices occasionally or focus on sustaining and improving what they’re currently doing for patient satisfaction.

Finally, the survey respondents expressed plain old confusion about what “the patient experience” is supposed to be. Is it the same as patient-centered care? Does it mean consumer-driven care? Or is it just a fancy version of customer satisfaction? Although many of the respondents equated “the patient experience” with “patient-centered care,” others who study this issue say it’s much more than this.

If the written comments submitted by many of the survey participants are any indication, most of them understand why the patient experience should matter. “Patient satisfaction brings the patient back to the organization,” one person wrote. “We know there are choices – we need to be the top choice.” From someone else: “Patients have options for where to go for their care, and they will choose the place that treats them as an individual with respect for them as a person.”

Is it all about money and market share? Well, yes, sort of – but when survey participants were asked what motivated them to improve the patient experience, guess what was at the top of their list? Improving outcomes for patients, followed by better patient satisfaction scores and retention of good employees and physicians.

It wasn’t that long ago when patient satisfaction was almost an afterthought – a nice extra but not essential to the hospital’s mission. These survey results make it clear the game is changing and that it’s no longer going to be the patient experience as usual.

West Central Tribune file photo

The weekly rundown, Nov. 24

Blog highlights from the past week:

Most-read posts: X marks the spot… not; Measuring medical care.

Up and coming: A calorie reality check.

Most-read from the archives: Bedside manner; Extreme, baby! Carrots.

Most blog traffic: Thursday, Nov. 18.

Link with the most clicks: The Minnesota Department of Health provider quality performance report from this post.

Search term of the week: “morgue toe tag.”

A calorie reality check

Just in time for Thanksgiving, the University of Minnesota School of Public Health is sharing a list of calorie counts for traditional Turkey Day foods.

Three ounces of turkey, with skin? That’s 156 calories, which would take 44 minutes of walking to burn off. A half-cup serving of mashed potatoes is 119 calories. Gravy? That’s another 18 calories per tablespoon.

The numbers come from a giant database maintained by the Nutrition Coordinating Center at the U of M’s School of Public Health. The database has been around for 35 years and is the only one like it in the United States. It lists calories, nutrients and other nutritional information for more than 18,000 foods and 7,000 brand-name products. Updated information each year helps ensure it remains current .

The old saying “you are what you eat” is right on the mark when it comes to the health implications of diet and nutrition. The initial purpose of the database was to support food coding and analysis for research programs on the impact of diet on conditions such as cardiovascular disease, cancer, high blood pressure, obesity and diabetes.

One of the major contributions of the database to nutritional science has been to standardize the methodology, making it easier for researchers to accurately analyze menus, recipes and food records. If researchers want to know the nutritional composition of chicken soup, for instance, they can consult the database. Ditto for information on specific brands of infant formula or miniature vs. king-sized candy cars.

So it’s safe to say that when the School of Public Health lists calorie counts, you can be certain they’re backed up by rigorous measurement.

The Thanksgiving menu they’ve shared includes all the familiar standbys, from stuffing and cranberry sauce to Jell-O, green bean casserole, candied sweet potatoes and pumpkin pie. If you consumed all 16 items in the amounts listed, it would amount to a whopping 3,300 calories – well beyond the recommended daily amount for an adult. It would take you 939 minutes of walking to burn them off.

As you might guess, dessert is the highest in calories. A slice of pecan pie contains the most, 526 calories. The least? Pumpkin pie, at 316 calories (whipped cream not included). I was surprised to discover that stuffing packs more calories (214 for a half-cup serving) than the turkey itself. On the other hand, it was reassuring to learn that half a cup of green bean casserole contains only 96 calories, which can be burned off with a 27-minute walk after dinner.

Does this mean you should skip Thanksgiving dinner, or feel guilty for having dessert? Not at all; the key, says Lisa Harnack, director of the U of M Nutrition Coordinating Center, is to have a little bit of everything rather than a whole of everything. Her advice: “A wonderful variety of great-tasting foods is one of the highlights of holiday gatherings. So, take advantage without overindulging by exerting portion control. With a dab of this and a dab of that you can keep on the right track.”

Measuring medical care

How do your medical clinic and hospital stack up with the quality of care they provide? A new statewide report, issued Thursday by the Minnesota Department of Health, lays out the details on performance measures for everything from heart attacks to diabetes, cancer screening and sore throats.

A fair amount of this data is already publicly available on sites such as Minnesota Community Measurement. But this is the first time it’s been gathered in one place and standardized for hospitals and clinics across the state. State officials see the report as the first step toward value-based health care in Minnesota – that is, rewarding quality rather than simply paying for procedures. The report also is meant to lay the foundation for provider peer grouping, allowing people to compare on the basis of both quality and cost and presumably make more informed decisions about where to seek health care services.

The report is a lunker. In fact, its sheer heft is somewhat of a drawback, when you consider the whole point is to make quality data more available and transparent for the average Minnesotan. The entire document is 800-plus pages long. It contains 43 quality measures for hospital care and 13 for physician clinics.

I’d rate its user-friendliness in the category of “daunting.” Kandiyohi County, for instance, is grouped into a geographic area that includes nearly 40 counties in southwestern, southeastern and south central Minnesota. The section is 242 pages long and I had to scroll through dozens of alphabetical listings until I found the data for Willmar. I notice the website designer remedied some of this today by breaking the report into smaller sections for easier reading, but it’s still quite cumbersome.

Once you get past these initial barriers, though, the findings are revealing. What leaps out is the degree to which hospitals and physician clinics in Minnesota vary on performance measures. Some do well across the board on most of the measures. But many are inconsistent, with good marks on some measures and not-so-good marks on others.

The million-dollar question: Will the report actually be used by consumers, and will it be used in a meaningful way? The answer isn’t entirely clear.

Although some people will have the hardihood to analyze all the numbers and choose their hospital or medical clinic on the basis of its quality performance scores, many consumers can’t or won’t. It’s not just that they don’t want to wade through all those statistics; it’s also about the other considerations that often go into people’s health care choices.

Some of it comes down to simple practicalities. I rarely see any discussion on how value-based consumer choice might apply to residents of greater Minnesota. Is it realistic to think someone living in a rural community can effectively comparison-shop when the next nearest clinic or hospital might be 30 miles (or more) away?

Nor do quality scores take into account the human element, which also matters to patients – whether the medical clinic has convenient hours and a user-friendly system for making appointments, for instance, or whether the patient feels he or she can have a trusting relationship with the doctor.

None of this means quality shouldn’t matter. Absolutely it does matter when consumers know they can consistently receive quality care that gives them good value for their money. But quality scores don’t tell the entire story and they’re not the only piece of information consumers should use in judging whether to go to a particular clinic or hospital.

The real value of this report, I suspect, will lie in the information it provides for hospitals and medical clinics to measure themselves against their peers and identify where they could be doing better. If this happens, ultimately all consumers will be better off, no matter where they happen to live or which provider they choose.

Photo: Wikimedia Commons

X marks the spot… not

Remember the episode from “ER” during which the abrasive Dr. Robert “Rocky” Romano was preparing to have surgery on his arm? He tells his colleague, Dr. Elizabeth Corday, “Do me a favor. Write, ‘Not this one, idiot’ on  my right arm. Oh, like it doesn’t happen!”

When wrong-site surgery becomes one of the staples of popular culture, you know the public awareness is high.

But not so fast, Dr. Romano. Although it’s generally assumed that patients ought to be engaged in helping to mark the surgical site, a new study suggests, rather surprisingly, that this assumption is faulty. The study was recently published online in the Journal of Patient Safety.

Two hundred patients scheduled to undergo orthopedic surgery were asked to mark their own surgical site ahead of time with the word “yes.” The majority, 68.2 percent, did so correctly – but 32 percent simply didn’t follow through.

Factors such as gender, education level, occupation and history of depression, which often can influence patients’ health behaviors, did not appear to make a difference, the study’s authors found.

A few of the other findings offer some clues, though. Patients who marked the site were slightly younger and more likely to speak English as their primary language than those who didn’t. The time between when they enrolled in the study and when they actually had their surgery also seemed to be predictive. Those who marked the site were enrolled in the study an average of 10.4 days before their surgery. For those who didn’t, it was 23.1 days, suggesting that timeliness might be important in getting patients more engaged in the process.

Significantly, none of the patients who marked their own site made an error, nor did they make any extra marks that could contribute to a wrong-site surgery. The real issue, the study’s authors conclude, seems to lie with motivating patients to participate in the first place. In view of the fact that more than three out of 10 patients in the study failed to mark the site as they were asked to, “patient involvement in surgical site marking is unreliable and may not help in decreasing the chances of wrong-site surgery,” they wrote.

These findings aren’t much different from a similar study done in 2003. In this case, the researchers followed 100 patients at a private foot and ankle practice who underwent elective orthopedic surgery. Fifty-nine of them marked the site correctly, 37 didn’t mark the site at all, and four marked the site but didn’t follow directions for how to correctly do so.

The authors offer a possible explanation: “This behavior suggests that patients expect the system to ‘take care of everything,’ despite solicitation of their active participation to avoid such adverse events.”

Avoiding wrong-site surgery seems like it would be easy. Those who study the process, however, are finding that it’s not. Often it’s the little things that create ambiguity. Should the correct site be marked with an X? Best practices now recommend against this, since an X can be interpreted in opposite ways: as “X marks the spot” or as “not this site.” Many clinicians now even make a point of using the word “correct” instead of “right,” to avoid confusion between right and left.

Although patients can be tempted to mark the site on their own, and perhaps add the warning “not here!” for good measure, many experts don’t think this is a good idea. For one thing, it bypasses the surgeon who’s doing the actual cutting. For another, once the patient is in the OR and prepped for surgery, these markings can be obscured by surgical drapes or blurred or dissolved by prep solutions, and lead to potentially disastrous confusion. For some of the same reasons, it’s not always preferable to have the site marked a week or two in advance of the surgery and risk having the mark rub off.

The recommendation that’s currently considered the gold standard is to have the surgeon, preferably with the involvement of the patient, sign the site with the surgeon’s initials. It’s all a work in progress, however, and it seems we still have much to learn about the best role for patients in making the process of marking the correct surgical site more consistently safe.

West Central Tribune photo by Ron Adams

The weekly rundown, Nov. 17

Blog highlights from the past week:

Most-read posts: Medicine and the social media; OTC? Get a prescription for that; Settling the score.

Most-read from the archives: Medical trivia quiz: the answers, published April 2 (What?? They looked at the answers first?); Room of horrors, from March 3.

Top referring sites: Wctrib.com; Grand Forks Herald.com; Inforum.com.

Most blog traffic: Tuesday, Nov. 16.

Search term of the week: “I hate flu shots.”

Settling the score

Was anyone else besides me disturbed by the news last week from a state veterans’ home in Hastings? Three officials have been placed on leave, and the facility is under investigation following allegations that residents, as well as some employees, may have been threatened with retaliation for complaining about the care.

The obvious question here, namely whether this is a common situation, was further fueled by a listing in the Sunday Minneapolis Star Tribune of Minnesota nurses who have had their license revoked this year for misconduct. Among them was a nurse who owned a home health agency in Plymouth and who is alleged to have given substandard care to a patient who filed a complaint about her.

Two instances don’t make a pattern, nor do they suggest these are anything other than isolated cases. But they’re concerning for the way they reveal an issue that’s rarely talked about openly in health care: the subtle and not-so-subtle ways health care workers can intimidate, bully or harass patients who might be perceived as troublemakers or just plain difficult.

It’s not clear how often this happens. I’d venture to guess the majority of health care professionals don’t behave this way, and most reputable institutions don’t tolerate it. Yet it does occur, as demonstrated by this recent entry on an infection control online message board, written by a nurse whose father experienced retaliation after expressing safety concerns while undergoing dialysis. She wrote:

Retaliation against patients comes in all sizes and all forms. This can be overt or covert – from staff rolling their eyes to a clear verbalization – telling the patient and/or designated advocate (family member) – never ask that question again, never question what I (staff) am doing.

She describes in chilling detail what happened when her 85-year-old father registered a complaint about a staff member in the dialysis unit who used contaminated gloves:

The staff retaliated against my father with such behaviors as staring and glaring at him, walking by him when he was receiving treatment and making little laughing noises, pulling in other staff to act the same way which resulted in many staff not being very nice.

Then there’s the nurse in Colorado Springs who was fired after being pulled over for speeding and complaining to the police officer, “I hope you are not ever my patient.” The story generated more than 350 comments on the New York Times website. Although the vast majority of the readers sided with the nurse, others were blunt about the implied threat. “I’ve worked in hospitals for 30 years and reviewed thousands of medical charts. Sadly, nurses do sometimes exact revenge – keeping a patient waiting for pain medicine, ignoring the call light for extended periods of time, bad-mouthing the patient to others on the health care team,” one person wrote.

From someone else:

Anyone who has ever been hospitalized with a critical health condition knows how vulnerable a patient is to accidental or intentional mishaps perpetrated by hospital staff. She’s the one who escalated the encounter, by hinting at the power she levies as a cardiac nurse. Sounds like a threat to me.

On the whole, it appears that retaliation by health care providers against patients is rarely reported. Patients and families are often reluctant to complain for fear of making the situation worse, especially if they aren’t in a position to seek care elsewhere. Retaliation also is somewhat fueled by perceptions and can be difficult to prove. (“We didn’t deliberately delay the patient’s pain medication. We were busy!”)

Doctors, nurses and other health care professionals are vulnerable themselves to retaliation if they report unsafe or substandard care. It’s not unheard of for them to be harassed or fired. In one of the more egregious cases, two nurses at a 15-bed county hospital in Texas lost their jobs and were charged with a felony after they blew the whistle on a staff doctor who they believed was endangering patients with unsafe care. They sued for damages and won, but the emotional cost of fighting this battle must have been enormous.

It has been fairly well documented that disruptive behavior takes place in the health care work environment. Health care is probably no better or worse than many other workplaces, but the stakes clearly are much higher when patients’ lives are on the line. Retaliation is one form of this behavior, so perhaps it’s not too surprising that at times it spills over into the staff’s interactions with patients. But it’s both unethical and against the law, and whether it’s directed at patients or staff, it shouldn’t be happening. Period.

Photo: Wikimedia Commons