Anatomy of a Safety Incident #1

One Friday evening a few years ago, I got a call from a freaked-out reception volunteer at WCA Hillsdale. Sarah, the manager and WCA’s safety manager at the time, happened to be out with the flu, so they reached out to me instead. A local rehabilitation center had just phoned to say there was a safety incident with a WCA patient and they wanted somebody to call them RIGHT AWAY.

Here’s what happened. The patient, let’s call him W., had been coming to WCA Hillsdale for about four months, several times a week. He had suffered a stroke which had left him unable to communicate verbally and also severely limited his mobility, which was why he was in the rehab center. His wife arranged the acupuncture treatments. She was also a patient, and usually they came together, with a rehab center attendant assisting with transport. Accommodating W. was a little bit of a logistical challenge, since he used a reclining wheelchair that took up enough space that the only place he was comfortable was in the (quite small) clinic waiting room. His wife sometimes got treated at the same time, and sometimes just sat with him. They both liked acupuncture a lot.

On the day of the incident, his wife happened to be out of town and so W. was dropped off at the clinic by an attendant, who didn’t stay. He was treated by acupuncturist A at 11:30 a.m. and unpinned by acupuncturist B about an hour later, because there was a shift change at noon.

The message from the rehab center was ambiguous (though urgent), but things really got interesting once an administrator, let’s call her V., answered the phone. For the record, acupuncturists aren’t the only people who lead off with safety issues by assuming that if something happens, the next step is to find someone to blame. V. started by telling me that our acupuncturist had left “four to five needles” “embedded” in W.’s shoulder, which were only discovered when he pointed to his shoulder with obvious discomfort. At that point the CNA who was working with him found the needles, got a needlestick, and then more needles were found in W.’s clothes. Also his bed! It was like a fountain of stray needles! The CNA went to urgent care due to the needle stick incident! Basically, V. wanted to know what the hell was wrong with WCA that our acupuncturists apparently buried needles in patients’ shoulders and then tucked some loose ones in, for good measure, for unsuspecting staff to stab themselves with.

I confirmed with V. that no, this was not something WCA wanted to have happen and said I would get more information. I got off the phone with her and called acupuncturist A -- who was taken aback. They said no, they had not in fact put any needles in the patient’s shoulder, and if they had they wouldn't have "embedded" them.

I called the rehab center and this time I got a nurse rather than an administrator; this time, also, I asked questions. According to the nurse, the total count of found needles was four or possibly five, and they’d been put in a sharps container by then. The nurse was a lot calmer than V. and also much more familiar with W. and his care. The nurse confirmed that W. wasn’t in pain and wasn’t upset. The CNA was okay too and not injured; they had gone to urgent care because they were following OSHA protocol for testing after a needlestick. I asked the nurse to pass on our apologies to W. and the CNA and they said they would.

It sounds like what happened is that at some point in W.’s treatment, either 4 or 5 half-inch needles fell out of his ear (he had received 5NP). The needles fell down his shirt and got stuck in his clothes; at some point later the needles scratched or jabbed his shoulder, and when the CNA checked out what was happening, the CNA was also scratched or jabbed. There had never been needles embedded in W.’s shoulder.

I tried to call V. the administrator back, but she had gone home for the day.

I tried to call acupuncturist B, but they didn’t answer, so I started an email thread with acupuncturist A, acupuncturist B, and Sarah. Over the next day we pieced together what had happened.

A significant element was the timing of W.’s treatment: it had overlapped a shift change. WCA shift changes are often busy for the acupuncturist coming on (B in this case) because patients from the earlier shift are wanting to get up at the same time that new patients are arriving. On the day of the incident, things had gotten somewhat chaotic because the attendant who had dropped W. off returned and insisted that W. needed to leave right then, which meant that acupuncturist B was rushed when unpinning him, as the clinic waiting room was filling up with other patients coming and going. That didn’t happen when W.’s wife brought him; she had a better sense of the rhythm of the clinic, being a patient herself, and was more likely to wait for a quiet moment to ask for W. to be unpinned. (W. often slept during treatments.)

Most importantly, though, because W.’s wife wasn’t there, nobody noticed when his ear needles fell out, and even if he’d noticed himself, he couldn’t easily tell them. B did a visual check of W.’s clothes for needles, but B wasn’t going to rummage around inside W.’s shirt.

Coming soon, an entire post about stray needles -- but suffice it to say for now that counting needles in and out isn’t a foolproof solution or even viable sometimes. One of WCA’s most important Swiss cheese safety elements for finding stray needles is enlisting patients to help check their clothes and their hair for stragglers. W. couldn’t help with this task himself, and the person who usually could and did -- his wife -- wasn’t there.

This safety incident was two-thirds about communication and boundaries and only one-third about stray needles.

In processing the incident, what became clear was that WCA couldn’t accommodate W.’s treatment without his wife’s help and presence. An attendant bringing W. and getting him settled in the waiting room wasn’t enough; we needed W.’s wife, who could communicate with him and us, and who had W.’s consent to check for needles inside his clothes. The boundary that WCA had to set was first with W.’s wife (we need your help or we can’t do this) and second with the rehab center (don’t schedule appointments for W. for acupuncture without his wife present).

In a culture where safety is interpreted as blaming and punishing people, the outcome could have been that WCA scolded acupuncturists A and B and then refused treatment to W., all in the name of “safety”.

What actually happened was:

Sarah scheduled a meeting with W.’s wife when she got back in town, went over what happened, and clarified what WCA needed from her. W.’s wife was grateful and receptive, and she and W. continued to get acupuncture at WCA for several more years without difficulty.

I called the rehab center, talked with V., and confirmed our protocols for treating W. I also let her know, and asked her to pass on to the CNA, that the possibility of bloodborne pathogen transmission from a solid-core, single-use acupuncture needle was vanishingly small. (Not that it changed their testing protocols, but just to alleviate anxiety.)

A, B, and Sarah had a good conversation about how to make shift changes smoother. Pro tip: if anything is going to go wrong at a community acupuncture clinic, odds are high it’s going to go wrong during some kind of transition like a shift change.

I wrote a detailed incident report, which was attached to W.’s chart (and which I just used to refresh my memory and write this post).

We didn’t have the AERD when this incident occurred, but this is a perfect example of what we hope acupuncturists will report.