“Ebola Blame” (October 12, 2014 email to Lisa Schnirring from Peter M. Sandman and Jody Lanard)
Today’s CDC briefing about the second Ebola patient in Dallas stressed the idea that the healthcare worker who became infected must have committed a “breach of protocol.” Tony Fauci of NIH used the same phrase in his comments on the event, and a lot of the media are running with that headline.
Arguably every hospital-acquired infection is technically a breach of protocol, since preventing all such infections is a goal of hospital protocols. But when most people hear the phrase “breach of protocol,” they imagine culpable carelessness or willful disobedience – not an inadvertent slip you don’t even know you made that permitted some part of your body to momentarily touch some contaminated part of your PPE.
In most people’s minds, “breach of protocol” implies that heads should roll.
At one point in the press briefing, CDC Director Tom Frieden said that “even a single inadvertent innocent slip can result in contamination,” a much fairer, more empathic way to describe what happened. But “breach of protocol” is the phrase that stuck. Even when the adjective “innocent” is added, as Dr. Fauci did at least once, this meme is grossly unfair to the healthcare workers of one Dallas hospital.
Worse, it is a dangerous meme. There are two competing interpretations of this second Dallas Ebola case: that Texas Health Dallas Presbyterian Hospital is terminally incompetent or irresponsible, or that we are expecting too much of U.S. healthcare workers. Maybe both are true. But if we focus on the former, we won’t pay enough attention to the latter – and to the nationwide changes that might make sense in response to the latter: more infection control training; different PPE when Ebola patients are being treated; active monitoring (not just self-monitoring) of the healthcare workers who treat them; identification of specially prepared facilities to which such patients are transported; etc.
It is easy to feel judgmental rather than vulnerable.
CDC Director Frieden has been insisting for months that an ordinary American hospital with ordinary PPE can safely take care of an Ebola patient, as long as everybody is consistently 100% “meticulous.” But everybody isn’t consistently 100% meticulous. That was the lesson of hospital-acquired infections long before this Ebola epidemic. It was the lesson of Madrid’s first Ebola case. Now it is the lesson of Dallas’s second Ebola case. Dr. Frieden should say so, apologize to America’s healthcare workers for having implied otherwise, and articulate nationwide policies that explicitly take human imperfection into consideration.
“Ebola Apology” (October 13, 2014 email to Lisa Schnirring from Peter M. Sandman)
Dr. Frieden’s apology at today’s news conference was better than no apology. He did clearly say he hadn’t intended to blame the nurse or the hospital. I am very glad he apologized.
What would a better apology have looked like? Something like this, I think:
I was widely and accurately quoted yesterday as calling the Dallas nurse’s Ebola infection a breach of protocol. It sounded to many like I was saying heads should roll. That misimpression is my fault. I should have said much more aggressively that a single, inadvertent slip can be tragic. And anyone can make such a slip. If I had made one myself when I was in West Africa, I wouldn’t want people calling my innocent mistake a “breach of protocol.”
I apologize to the infected nurse, to everyone at the hospital where she works, and to healthcare workers around the country.
An even longer apology would be even better – but this is undoubtedly too long for you to use, and probably too long for a CDC news conference as well:
I apologize to the infected nurse, to everyone at the hospital where she works, and to healthcare workers around the country for what I said yesterday about the Dallas nurse’s Ebola infection.
One, I should have said that we don’t know yet if the problem was with the protocol or the equipment. Statistically, the protocol is more likely. But we don’t know. Human error versus equipment malfunction is a question that should never be prejudged, and I prejudged it.
Two, I should have emphasized much more that the big question is whether we’re expecting too much of American hospitals and the people who work in them. Blaming one nurse or one hospital isn’t fair.
Worse, it isn’t smart. We need to reconsider whether it makes sense to continue to recommend protocols that require people to be 100% meticulous – a word I know I have used too much, as if “meticulous” were easy. Nobody can be 100% meticulous all the time. So we are rethinking a lot of things: more training of healthcare workers, of course, but other possibilities as well: moving Ebola patients to specialized facilities; sending in specially trained teams to manage Ebola patients where they are; reclassifying healthcare workers who help treat Ebola patients as high-risk contacts requiring active monitoring; etc.
I was widely and accurately quoted as calling this a breach of protocol. It sounded to many like I was saying heads should roll. That misimpression is my fault. I should have said much more aggressively that a single, inadvertent slip can be tragic. And anyone can make such a slip. If I had made one myself when I was in West Africa, I wouldn’t want people calling my innocent mistake a “breach of protocol.”
List of Ebola Risk Communication articles.
Copyright © 2014 by Peter M. Sandman and Jody Lanard