Anatomy of a Safety Incident #3

POCA Tech has had a number of off-site student clinics over the years. This post is about a multi-faceted safety incident that happened at one of them, and some lessons we learned from it about making safety.

Typically what happens with an off-site clinic is that POCA Tech’s partner organization gives us the use of a specific room for acupuncture. In this instance, the acupuncture room had space for up to twelve patients receiving acupuncture as well as a sign-in area and a supplies cart. The supervisor also had a small, separate office for charting just across a hallway, and if the clinic space got busy enough, the supervisor would need to move to the office in order to not to take up a chair that could otherwise be used for patients; the supervisor stepping back also allows the interns to get real-time practice in holding space in the clinic.

This particular incident involved a patient with schizophrenia, who had previously received acupuncture once or twice over the past year but had never been a “regular”. During a busy shift in which the supervisor was across the hall, the patient suddenly reached out and grabbed an intern’s hip. The intern stepped back, shocked. At that point, other patients who hadn’t yet been needled jumped up to intervene. One went to get the supervisor while the others protectively hustled the intern out of the acupuncture room.

The supervisor checked in with the intern, who was somewhat in shock, and then went to talk to the patient who had grabbed her. The supervisor told the patient that he couldn’t touch people like that in the clinic space, and he needed to leave. He refused, at which point the supervisor went and got the security guard on duty, who succeeded in getting the patient to leave the clinic space. At that point the other patients and the intern went back in and treatments resumed.

An hour or so later, when no patients were being treated, while the intern and the supervisor were hanging out in the clinic space waiting for the next wave of people, the patient who had grabbed the intern came back. The supervisor didn’t want to leave the intern alone with him to get security, so she told him firmly that he needed to leave. He was not overtly aggressive at that point but was scowling at them, and the supervisor felt he was in an altered state. After some time and effort on the supervisor’s part, he did leave.

After the shift was over, the POCA Tech supervisor went to the program manager of our partner organization, described what had happened, and asked that this patient not be offered further treatment in our acupuncture room. And then things got interesting, because the program manager refused. She insisted that the partner organization’s commitment to Trauma Informed Care required him to continue to have access to treatment, including acupuncture. She said he was having a mental health crisis and he needed any support he could get.

While the POCA Tech supervisor was mulling over what to do about this conflict, the patient returned to the clinic space the next day when a different acupuncturist was working (alone, not with student interns). That day, the patient didn’t grab any humans -- but he did grab needles. He kept touching things on the supply cart until the acupuncturist asked him to stop. At that point, he found a fallen needle on the floor, picked it up, and jabbed it into his thigh. The acupuncturist asked him to leave the clinic space; once again he wouldn’t go; once again the acupuncturist had to get the security guard to escort him out. He may have left with a stray needle still in his possession.

The acupuncturist wrote an incident report and checked in with the POCA Tech clinic supervisor about what had happened. She then called me and said, we have a problem.

Wow, I said. Indeed we do.

After we spoke, I called the program manager’s boss in our partner organization, in order to deal with the urgent matter of making sure this patient didn’t come in to the acupuncture room again -- and also to schedule a meeting to unpack what was going on and what we were going to do about it.

In advance of that meeting, POCA Tech staff needed to do some unpacking ourselves, to figure out how to approach our partner organization. We already knew that this relationship between our organizations was like any committed long term partnership -- it required that both sides work on it. We already knew that communication was something we had to pay attention to; now we realized we also needed to be very thoughtful and intentional about our boundaries.

This seems like a good time to insert this diagram (which I don’t remember if we had when this particular safety incident was unfolding):

hierarchy of needs pyramid

As acupuncturists, our primary responsibility is the physical safety of our patients and ourselves. There’s a lot we have to pay attention to in the course of doing our jobs, but physical safety is what comes first. It’s an order of operations issue.

As a result, there’s always a dynamic tension between safety and access. You can’t treat someone if you can’t treat them safely -- which means unfortunately you can’t treat everyone. Even though, as a community acupuncturist, you want to treat everyone.

In the case of this particular patient, the reason we couldn’t treat him was not that he was in a mental health crisis, or even in an altered state; it was that his behavior wasn’t safe enough to be in a community acupuncture clinic. We have unfortunately had experience with other patients, who had no apparent mental health issues and were not in altered states, who also grabbed or touched practitioners inappropriately and who also helped themselves to needles. (Okay, jabbing oneself intentionally with a stray needle is a remarkable new variation on that theme -- but it’s still just a variation on a theme.) Those other patients’ behavior was also a deal-breaker for receiving treatment with us, because on some level a community acupuncture clinic functions like a collaboration between the patients and the acupuncturist. Everybody has to help make a safe-enough environment for treatment to happen. Plenty of patients with severe mental health problems (including altered perceptions) do a perfectly fine job with that, while some patients with no mental health problems can’t manage it.

When we met with our colleagues in our partner organization, everyone affirmed our commitment to Trauma Informed Care and to our ongoing relationship. I said something like, “So -- as licensed acupuncturists, we have some very specific responsibilities to the State of Oregon. One of those responsibilities is managing the needles that the state lets us use. We are obligated to make sure, as best we can, that only clean needles go into patients’ bodies and that dirty needles go only into biohazard containers. Dirty needles intentionally going into a patient’s body, or going out the door with someone who’s going to do God knows what with them -- we just can’t. The work we do here has to be in compliance with our obligations, or we can’t do it.”

Which made perfect sense to our partner organization.

As a result of that meeting, we figured out some ongoing communication measures that we needed to add to our routines. The main outcome, though, was an awareness on both sides that the acupuncture room, though located in a building owned by the partner organization, in a sense was part of a separate universe -- the universe of licensed acupuncturists, who have particular boundaries and limits and needs.

And also that Trauma Informed Care involves a dynamic tension between safety and access, which requires continual communication to navigate. As an acupuncturist, the more access that you want to create, the more structure you will need. Access doesn’t only mean taking down barriers; it means creating a container that works for as many people as possible. (It isn’t really access if you have nothing but chaos to offer people once you let them inside.) And because of the nature of acupuncture itself, there will always be certain limits to that access.

This incident is also a good illustration of how making safety has both individual and organizational components. When the patient grabbed the intern, the other individual patients in the room acted together, in the moment, to make the situation safer by getting the intern out of the room and notifying the supervisor. The POCA Tech supervisor, in turn, did what she could as an individual to set boundaries with the patient and also, to communicate and reach out for help. When her first request for help wasn’t heard, she tried again; she persisted until she got a response.

However, there was a crucial part of safety-making that had to happen at the level of organizational communication, boundaries, and policy. It’s neither fair nor realistic to put all responsibility for safety on individuals. (See also: pandemics.) POCA Tech as an organization had to clarify that there might be differences between patients who could participate in our partner organization’s program and patients who could get acupuncture from us. POCA Tech had to take ownership of our own safety needs for providing acupuncture and then communicate them to our partner. Both organizations needed to commit to continual, proactive communication -- more communication than either party expected when we started the partnership.

Finally, this incident was a good example of setting positive boundaries. Certainly the experience was stressful, and everybody involved was frustrated at times. But in the end it was about POCA Tech saying yes -- yes to our continued relationship with our partner organization, yes to our acupuncture space as a strong container, yes to making safety that’s active, participatory, cooperative, and relational.