Thomas was admitted to the emergency room with a high fever and complications stemming from a staph infection that he had acquired at the hospital several months previously. The nurse assigned to him was visibly distracted the entire time she was speaking to him. She hooked him up to an automatic blood pressure machine and left the room. The machine continued to run on automatic, taking his blood pressure every few minutes. Thomas drifted in and out of sleep because of his high fever. He had the chills, but although he had asked his nurse for a warm blanket, the warm blanket never arrived.

Thomas wished that his wife Susan had been able to come to the emergency room with him that day, but she had to work, and due to Thomas’ rising medical bills, Susan could not risk skipping work. Thomas’ sickness was creating a huge strain on their marriage as they both struggled to get through the experience together.

Thomas soon noticed that the blood pressure cuff was attached to his left arm above the peripherally inserted central catheter. The PICC line had been inserted weeks earlier to receive intravenous antibiotics. Thomas knew, from common sense and also from reading the numerous signs around the hospital that stated “NO BP on PICC LINE ARM,” that blood pressure should NEVER be taken on the arm that has the PICC line in it. Doing so can cause the formation of blood clots, catheter breakage, leakage, and other serious complications. Thomas immediately ripped the blood pressure cuff off his arm and called for his nurse.

Through the curtains surrounding his cubicle, Thomas saw his nurse standing at the nurse’s station, laughing with another nurse and dancing around (she was listening to her I-pod). Finally, Thomas got her attention and she sauntered into the room. Thomas told her what had happened. The nurse said that the blood pressure cuff “could not have been pumping automatically” as she had only set it to take the blood pressure once. Thomas knew that the blood pressure machine had been taking his blood pressure continuously for the past half hour. The nurse was either mistaken, or she was lying. When Thomas asked her how she could be so negligent as to put the blood pressure cuff on his “PICC line arm,” she responded: “Look, what’s done is done. What do you want me to do about it?” Thomas asked for a new nurse and one was assigned to him. He also complained to the first nurse’s superiors, to no avail. In fact, the nurse’s manager defended the nurse and said that he highly doubted that the blood pressure machine had been pumping for half an hour. “No harm done anyway,” the nurse manager said. Thomas was horrified, but had no more energy to argue and so he let the matter go.

Thomas was lucky that no permanent damage occurred as a result of his nurse’s incompetence, but he could not help but wonder how many other patients might not be so lucky.

Janet’s thirteen-year-old daughter Kristen, who was battling leukemia, was in the hospital for her regular dose of chemotherapy. Janet rarely left Kristen’s bedside, but she wanted to go to the bookstore across the street from the hospital to get her daughter a book that she desperately wanted. Kristen was lying in bed watching television, and Janet thought this would be the perfect time to rush out to the store and come right back with the book. When Janet returned to Kristen’s hospital room, however, she found that the bed where her daughter had been lying had been stripped of its sheets. There were four nurses in the room covered from head to toe with protective gear and goggles, carrying cleaning supplies. Janet was starting to panic when she saw Kristen sitting on a chair to the far left of the bed.

Kristen had needed to go to the bathroom. She had buzzed for her nurse to come, but after waiting for five minutes, she worried that she would wet herself; so she decided to try to get to the bathroom by herself. After all, the bathroom was only a few steps away from the bed. What was the worst that could happen?

Unfortunately, in her somewhat drugged state, Kristen had forgotten that her arm was connected to the IV pole. When Kristen walked to the bathroom, she accidentally ripped the IV out of her arm. The bag of chemotherapy liquid that had been dripping slowly into her veins burst and spilled all over the floor. Kristen pulled the emergency cord, and the nurses rushed in. When the nurses realized what had happened, their first order of business was to protect themselves with special clothing, goggles and masks—so as not to inhale the toxic fumes or come into contact with the dangerous yellow liquid. Kristen, however, was given NO protective gear or goggles. In fact, the nurses were hardly paying any attention to her at all. Janet noticed that her daughter’s arm was dripping blood (from where the IV had been torn). Janet led her daughter out of the room as quickly as possible, in utter shock at what she had just witnessed.

Later, when Janet asked the nurses why her daughter had not also been provided with protective clothing, goggles and a mask, the nurses merely stared at her blankly. “It was as if protecting Kristen had completely slipped their minds, and they did not know what to say to me,” said Janet. Janet never left Kristen alone in the hospital again, not even for five minutes.

Sharon had been discharged from the hospital and was receiving care at home for a condition that was now stable. She, like Thomas, had a PICC line in her right arm through which she received medication. The visiting nurse, Paula, arrived at Sharon’s home one Friday morning, as she had many times before, to clean Sharon’s PICC line and change the dressing. However, this time Paula was unable to unscrew the pieces of the PICC line that she needed to replace. After struggling for about 15 minutes, Paula spotted a wrench that was sitting on the coffee table; it had been left there by Sharon’s stepfather who had been fixing some things around the house earlier that week. The nurse grabbed the wrench—a dirty, unsterilized tool—and used it to unscrew Sharon’s PICC line. Sharon didn’t think this was right, but she didn’t feel comfortable questioning Paula. After all, Paula was the nurse: surely she knew what she was doing, Sharon reassured herself.

The very next morning Sharon had to be transported by ambulance to the hospital. She was diagnosed with an E. coli blood infection, stemming from her PICC line. Sharon was in the hospital for two weeks to treat the infection. While there, as if she didn’t have enough to deal with, she acquired clostridium difficile (also called C.diff). It is a common hospital-acquired infection that often gets transmitted from patient to patient by nurses and other caregivers who do not follow safety protocols, and change their gloves and gowns before going from one patient’s room to the next. Sharon had seen nurses entering her room without changing their gowns and gloves, but had said nothing. Now she wished she had spoken up or had someone by her side to watch out for her. “I thought I could trust my nurses to do the right thing,” said Sharon, shaking her head.

When Sharon called the home health company that employed Paula and told the person in charge what happened at her home that day, she was told that the company would investigate the matter and get back to her. Nobody ever called Sharon back, and so she called the company again one week later. This time Sharon was told that Paula had denied that she had used a wrench on Sharon’s PICC line, and that management saw “no reason not to believe her.” No reason not to believe her?! Sharon could not believe what she was hearing. The manager was basically accusing Sharon of lying. Sharon had no reason to lie, whereas Paula (who presumably could have lost her job if she had admitted what she had done) had every reason to lie. Sharon, sick with the infections and exhausted by the responses she was hearing, let the matter go.

Paula still works full-time at the home health company, and still sees patients in their homes on a regular basis.