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Green Spring Celebrates 10 years
Reception: Wednesday, June 30, 6 p.m. to 8:30 p.m. (Invitation only)
All-Employee Picnic: Thursday, July 1, 11 a.m. to 2 p.m.
All Hopkins employees, patients and other tenants invited.


The Power of One
How a nurse's hunch led to a new level of safety for patients nationwide

Nurses Diane Iverson and Susan Fanske.
Two years ago, a sprinkling of patients in the Outpatient Center’s urology clinic began experiencing unpleasant reactions after they came in for endoscopic procedures. Most clinicians involved assumed that a few odd symptoms here and there—hives, tightness in the chest—were simply isolated events connected to the patients’ anxiety about having their bladders examined for tumors.

Diane Iverson could have made the same assumption. But the veteran nurse had a nagging suspicion that ate away at her and compelled her to speak up. As the reactions became more frequent and serious—landing some patients in the emergency department—Iverson relentlessly followed a trail that would lead her to the source of the mysterious reactions. Little did she know that her pursuit would involve a leading medical product manufacturer and help put an end to a national problem.

Increasingly, practitioners are turning to computer technology to help avert situations that can harm patients. But, as Iverson’s story clearly illustrates, one sharp-eyed and persistent human being can make all the difference when it comes to unraveling the web of circumstances that can lead to harm.

“Diane was tenacious and brave in pursuing this,” says Patrick Walsh, director of urology. “She took the problem personally and identified something that no one here had ever seen before.”

The first reaction occurred in a bladder cancer patient who, like many others, came into the clinic every three months for a cystoscopy, a procedure in which the bladder is checked for new tumor growth. After the procedure, the man complained he had trouble catching his breath. In the man’s chart, the attending attributed the reaction to “standing up too fast.” That was October 2002.

At that time, each cystoscope—for men, a long, flexible rubber tube; for women, a shorter, metal tube—was cleaned by hand. The process began with a tub filled with soapy water and a metal brush to remove large proteins from inside the tube. That was followed by a rinse and a lengthy soak in CIDEX OPA, a disinfectant cleaning solution manufactured by Johnson & Johnson. Finally, the disinfectant was rinsed off in another tub, using sterile water.

Iverson had always been wary of the wide margin for human error in the cleansing process. “One person’s interpretation of vigorous scrubbing might be different from someone else’s,” she says. The volume of water used to flush the disinfectant away could also vary. “Still, we followed the instructions and considered what we were doing to be completely sterile.”

Over the next year, there were scattered adverse reactions, but it wasn’t until late 2003 that a pattern emerged. When Iverson shared her theory with veteran nurse Susan Fanske, Fanske pointed out that all four patients who had reactions—most more than once and some so severe that they required hospitalization—were male, and all were bladder cancer patients. Bolstered by Fanske’s participation, Iverson set out on a quest to find the source of what both nurses now believed to be allergic reactions.

Other practitioners chalked it up to stress. “But there were too many clinical signs to assume that,” insists Fanske. “Patients’ blood pressure dropped, their oxygen saturation levels were down, and they had severe, full-body itching.”

Near the end of 2003, there were five reactions in just a few months. (The outpatient clinic performs 1,700 cystoscopies each year, averaging about 10 a day.) Iverson and Fanske had already started to rule out every possible allergen in the environment, starting with the latex gloves. The patients went for allergy tests. And the two nurses continued until they’d eliminated everything, bar one: CIDEX OPA.

By this time they were premedicating the patients who’d reacted previously, attempting to prevent the attacks on subsequent visits. And yet, the reactions continued. One man developed the worst hives Iverson had seen in her 11 years as a nurse, his lips and tongue swelling like balloons. Another, itching like crazy, was red to the whites of his eyes. Then, in February 2004, a patient’s blood pressure dropped by half right on the exam table.

The nurses were prepared. Everyone knew who had what role in a code situation and the allergic reaction supply box was up to par. The nurses had already invited Johnson & Johnson to observe their methods and had taken the rep’s suggestions for improvement, including increasing six-fold the volume of water needed to flush off the disinfectant.

Iverson had also presented the case to Anna Rice, director of outpatient services, Richard “Chip” Davis, executive director of the Center for Innovation in Quality Patient Care, and Walsh. The three quickly approved funding to upgrade by August to an automated cytoscope cleaning system, which would standardize the amount of water, disinfectant and time.

“They decided that even though there was no data to prove anything, they were willing to go with a nursing hunch,” says Iverson. When all was said and done, she says, it would translate into $40,000. “That big chunk of change says, We’re listening.”

Then, in late April, after receiving 17 reports of similar cases throughout the United States, Johnson & Johnson issued a contraindication warning for CIDEX OPA. Using the solution on patients with a history of bladder cancer, health care professionals were advised, could result in hypersensitivity, as these patients had multiple and frequent cystoscopies. Iverson’s hunch had been entirely born out.

With the new warning, the urology clinic stepped up plans for installing the new cleaning system. Facilities’ Sean Nelson swung into action to prepare a space for the two scanner-size machines. Within five business days, he had the plumbing in place for the water filters, the room wired, and shelving and storage cabinets built. Two days later, the system was up and running. There have been no reactions since.

Lindsay Roylance



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