Joe’s email came in at 9:10.
FW: CISA advisory this morning. See below. This is basically what we’re already doing. Keep the green tags. We’re doing it right. — J
Dolores scrolled through the advisory. It was a page and a half of bureaucratic nonsense. She paused when she got to the stuff that mattered for her. Retain devices in clinical service. That was the green tags. Inventory affected assets. That was the book, and the asset system, and Kevin’s board.
She closed it and went back to the pump on the bench. She was halfway through fixing a cracked door latch. There were forty-four green tags on the floors now.
At ten-twenty Terri came down. She didn’t lean on the door frame this time. She came all the way in and stood by the bench with her arms folded, and she was pale. Dolores wished she had the courage to ask Terri out for a beer after work.
“You got a minute?”
“Sure.”
“The new heparin,” Terri said. “It won’t go in the library.”
“I know. I tried to load it Monday.”
Pharmacy had switched heparin bags the week before because of the shortage. The old bag and the new bag looked almost the same, but the new one held twice as much heparin. Pharmacy had sent a new drug library down on Monday so the pumps would know the difference. Dolores had plugged the first pump into the laptop, pushed the library, and watched it get most of the way and stop. LIBRARY PACKAGE NOT VERIFIED. She had tried a second pump. The same thing had happened. She had called pharmacy, which had sent a memo to the floors that afternoon that every med room now had taped on the wall.
NEW HEPARIN 100 UNITS/ML — NOT IN PUMP LIBRARY. PROGRAM IN BASIC MODE. CALCULATE RATE MANUALLY. INDEPENDENT DOUBLE CHECK REQUIRED.
“We had an agency girl on nights,” Terri said. “Nice kid. First week. She hung a new bag on four-twelve at five this morning, in basic mode, and programmed it at a hundred and eighty.”
Dolores set her screwdriver down.
“It should have been eighteen.”
“Yes.”
“How long?”
“Forty minutes, give or take. I caught it at handoff because I’m nosy and I look at everybody’s pumps.” Terri unfolded her arms and folded them again. “She’s eighty-one. She’s up in the unit now. They think she’s going to be okay. They’re watching her for a bleed.”
Dolores sighed. If the pump had the library in it, the kid would have typed a hundred and eighty and the pump would have stopped her cold, beeped at her, and made her call somebody. In basic mode it didn’t know it was heparin. It didn’t know anything.
“Did the double check happen?”
“The other nurse on nights had eight patients and a code on six,” Terri said. “She initialed it. She says she looked.”
“Okay.”
“It’s not okay, Dolores.”
“No,” Dolores said. “It isn’t.”
Terri looked at the rack of pumps with their tags.
“Can you get the library on?”
“I’ve tried it on six. It won’t take.”
“Then what am I supposed to do?”
“Check everybody’s pumps,” Dolores said. “Like you did.”
Terri turned without saying a word and went back upstairs.
Dolores called Corbin. The hold music was the same shitty hold music. After eleven minutes Mary picked up and read her the greeting. Dolores told her about the library.
“Yes, we’re aware of that one,” Mary said. “It’s a known issue. It’s been escalated.”
“Escalated to who?”
“I can’t give you a timeline.”
“That’s not what I asked.”
“I’m sorry,” Mary said, and sounded like she meant it, and gave her a case number.
Dolores sat for a minute with the phone in her hand and then hung up. She went and found Joe.
He was in his office on the first floor with the door open and a sandwich on the desk. He listened to the whole thing without interrupting.
“The library fails with the same message the firmware does,” she said. “Word for word. Whatever’s wrong with the updates is wrong with the library.”
He took his glasses off.
“Jesus,” he said. “Is the patient okay?”
“They think so.”
“Okay. Good. That’s good. Thank you for coming up. Seriously. This is exactly the kind of thing I need to know about.”
“We need to pull the new heparin bags off the floors until the library goes on.”
“We can’t. There aren’t any old ones. That’s why we have the new ones.”
“Then we need somebody to get the library on,” said Dolores. “We’re waiting on Corbin. And I don’t think they have a clue what is going on.”
“Put in a safety event,” Joe said. “I’ll call pharmacy. And Dolores — the advisory this morning says keep them running. That’s the federal government. That’s not me.”
She went back downstairs and opened the safety event system, which was yet another system she didn’t trust. Once again she needed to enter a category. She chose MEDICATION — INFUSION DEVICE. It wanted a severity. The choices were NO HARM, HARM — TEMPORARY, HARM — PERMANENT, and DEATH. Someone was going to die because of this, but she knew they’re watching her for a bleed didn’t count as death, so she clicked TEMPORARY. There was a box for a description that took two thousand characters. She wrote a long description, including “IF WE DON’T FIX THIS SOMEONE WILL DIE” at the end and hit Save.
Then she called Patient Safety.
Karen Mazur picked up on the second ring. Dolores had met her twice, once at a fire drill and once at a retirement party. Karen seemed nice enough but she wasn’t Dolores’s type.
“Dolores. I just saw your event come in. Thank you so much for reporting this.”
“I want to make sure somebody read it.”
“Hang on.” Dolores waited about twenty seconds. “Oh, I read it. This is exactly what we want reported. And I want you to know —”
The fire alarm went off.
It was the second Tuesday of the month, which meant it was a test. The horns in the basement were loud enough to feel in her teeth and the strobe on the ceiling flashed white across the rack of pumps. Dolores put her hand over her other ear and said “Karen, I can’t hear you,” and Karen’s voice went on talking under it, small and reasonable, for about thirty seconds.
The alarm stopped.
“— so that’s what we’ll do,” Karen said. “Does that sound good?”
Dolores did not ask her to repeat herself. Instead, she said, “What are you going to do?”
“We’ll send a safety huddle message to all the nursing units this afternoon reminding everybody about the independent double check for basic mode. And I’ll make sure it’s on the agenda for the medication safety committee. That meets on the nineteenth.”
“That’s it?”
“Dolores, the advisory this morning is very clear. We can’t take the pumps out of service. We don’t have replacements. What we can do is make sure the process around them is as safe as we can make it.”
Dolores felt her heart sink, but she didn’t know what else to say. This was getting worse and no one seemed to take it seriously enough.
“Thank you again. Really. Good catch.”
Dolores hung up. She got the book down off the shelf, third from the left, and turned to the day’s page and wrote the date and:
4W rm 412. New heparin (100/ml) not in library — library won’t load (6 pumps tried, same msg as fw). Pump in basic mode. Programmed 180 vs 18 ~40 min. Caught by T. at handoff. Pt to ICU for obs. Told J. in person. Safety event #. She copied the number off the screen. Called K. Mazur, Pt Safety. Huddle msg to nursing, med safety committee on 19th. Thanked.
At two o’clock a bed scale came down from 5. It read eleven pounds with nobody on it. She zeroed it out.