Why We Do This, Part Two

Published in on Apr 20, 2022

Patient safety has been in the news lately due to the tragic case of nurse RaDonda Vaught, who was convicted of criminally negligent homicide as a result of giving a patient the wrong medication. There’s a good piece in the New York Times that addresses the difficulty of creating a culture of safety in healthcare:

“When patient safety experts talk about medical errors in the abstract, in lecture halls and classrooms, they talk about a culture of patient safety, which means an openness to discussing mistakes and safety concerns without shifting to individual blame. In reality, however, conversations around errors often have a different tone. ...when a patient is harmed, it is natural to look for a person to blame, a bad apple who can be punished so that everything will feel safe again. It is far easier and more palatable to tell a story about a flawed doctor or a nurse than a flawed system of medication delivery and vital sign management. But when it comes to medical errors, that is rarely the reality. Health care workers and the public must acknowledge that catastrophic outcomes can happen even to well-intentioned but overworked doctors and nurses who are practicing medicine in an imperfect system. Punishing one nurse does not ensure that a similar tragedy won’t occur in a different hospital on a different day. And regardless of the sentence that Ms. Vaught receives in May and whether it is fair, her case must be viewed as a story not just about individual responsibility but also about the failure of multiple systems and safeguards. That is a harder narrative to accept, but it is a necessary one, without which medicine will never change. And that, too, would be a tragic error but one that is still in our power to prevent.”

Acupuncturists are lucky that the errors and adverse events we encounter in our practices are almost never life-threatening. Nonetheless, we need to be able to talk about them. It takes a lot of work to establish an environment in which people are willing to share information about unintended outcomes and things that go wrong. So I was very happy to receive the following email from a POCA Tech student:

“After reading “Why We Do This, Part One” I wanted to follow up with a recent AE I heard about a fellow acupuncture student experiencing. Having learned about moxibustion in a recent lecture my friend decided to try it out on one of their acquaintances who they already had extensive experience practicing acupuncture with. The person they treated dealt with chronic pain in their knee and was experiencing recent back pain so they were excited to see how they liked the warm soothing effects of moxa.

My friend is cautious about practicing considering they know that they’re not allowed to practice outside of school supervision. They do their best to eliminate as many aspects of risk as possible: the setting, the patient, the process, everything is considered for risk before they say yes to giving a treatment. But this was their first time ever doing moxa outside of the classroom. They were enthusiastic to try it out particularly because it seemed pretty safe. Still, they took all the precautions they could think of. They opened the windows, turned on the overhead fan, and ran an air purifier they had in the room.

Honestly, the moxa sounded like an immediate success. The patient friend felt a warm soothing sensation that eased their pain and could actively notice a difference from the moxa. Another housemate walked in and my friend offered them moxibustion as well since they already had a moxa stick going. They treated the housemate as well. When they were done they extinguished the moxa, hung out for a little bit, and then eventually returned home. Everything seemed successful and they were excited to add a new tool to their toolkit.

The next morning my friend woke up to over a dozen messages on their phone. Apparently, a little while after they left the friend they had treated had started feeling really nauseous. There was a variety of text messages describing the nausea, the lingering moxibustion scent they felt like they couldn’t get away from in the house, and a sensation they described as their body “humming.” At best they described the situation as “incredible, if extremely inconvenient.” Turns out the moxa had made them so nauseous that they couldn’t stay asleep through the night and had to actually call in sick to work the next day. They washed all the sheets and blankets that had been in the room moxa was done in, but they still took most of a day to feel normal again.

Waking up to those texts my friend’s acupuncture career flashed before their eyes. They were hit with immediate guilt. They had not only unintentionally harmed a person by making them ill, that person was going to experience financial ramifications by not being able to perform at work the next day. Also, they were worried about their friend! Simultaneously though, they realized how unexpectedly something could go wrong. If the wrong person had experienced the side effects their friend had, the person they treated could easily get mad and lash out by reporting the student, posting about it online, or telling a medical professional or another licensed practitioner who could potentially report the student for breaking the law by practicing without a license.

It was a Catch 22 moment where my friend realized more significantly than ever how deep a risk and how much trust they were placing in people when they offered treatments outside of supervised academic settings, however they also wanted to understand what happened and what went wrong. Thankfully they were in a position to get appropriate guidance, and then were able to better counsel their friend and patient about the side effects they experienced, and were eventually able to move past the guilt from the Adverse Event, even though the lesson about extracurricular treatment risk very much stuck with them.

Even wilder, my friend was back visiting their moxa guinea pig a few days later and ran into the housemate again. The housemate casually brought up that the moxa treatment horribly triggered their PTSD because they had experienced severe burns as a kid. Not only was this another Adverse Event from the same evening, my friend who gave the treatment had no idea the AE ever occurred! It was simply because they ran back into that housemate and the person had casually brought it up that they found out. So it’s a good reminder that even if a student isn’t witnessing AEs from their needling or treatments that doesn’t mean they’re not happening or the risk isn’t there.”

POCA Tech’s policy about extracurricular needling is different from other acupuncture schools’ and this email illustrates exactly why. It’s hard for students (and also licensed acupuncturists!) to wrap their minds around the range of ways that people can respond to acupuncture -- or in this case, moxa -- which in turn makes it challenging for them to learn how to manage risks associated with treatment. It’s hard to take risk seriously when it doesn’t feel real! And often the only thing that can make risk feel real is firsthand experience of an unintended outcome.

The Clean Needle Technique Manual has this to say about nausea and moxibustion: “Allergies to the moxa smoke, or response to the volatile substances such as borneol in the moxa smoke may create nausea or allergic reactions. “Under normal operating conditions neither volatile nor carbon monoxide [associated with moxa smoke] would present a safety hazard.” (6) With proper ventilation, the toxicity of moxa smoke is probably minimal.” (pg 25)

I don’t know about you, but reading that paragraph doesn’t make me think, “Wow, I’d better think twice before breaking out the moxa because even if I open a window AND put on a fan AND use an air purifier, my patient could be racked with debilitating nausea! (And also I could trigger their housemate!)” Back when I had a private practice, I used moxa (sometimes in poorly ventilated spaces) and I never had a patient respond with debilitating nausea or a PTSD trigger. Because that’s the nature of risk: The bad outcome doesn’t always happen -- the bad outcome is a possibility.

It’s certain that humans will make mistakes. That’s not just a possibility, it will definitely happen! Also, humans learn from mistakes. Punishing humans for the mistakes they make doesn’t eliminate mistakes, it just makes humans unwilling to talk about them -- which means nobody else can learn from those experiences. And given how hard it is to have a healthy, balanced relationship to risk, we can’t afford to miss out on any opportunities to learn from other people’s mistakes. At POCA Tech we try to mitigate the risk of bad outcomes from human error by making it safe(r) to talk about risks and mistakes, boundaries and judgement calls, and all the things that can go wrong even when you think you did everything right. Thanks to everyone, particularly students, for engaging in -- and especially initiating -- positive conversations about safety.