The Wrong Patient

TO THE EDITOR:

Chassin and Becher (1) describe perfectly the uncoordinated care that, if not characteristic, is certainly episodic in so many of our hospitals. At a macro level, it is time to concede that the current organizational structure of our hospitals cannot ensure a consistently high level of safety for our patients. Safe, timely, satisfying care cannot be provided in a system that lacks point-of-service management presence. At a micro level, this is most visible throughout the United States in the elimination of the traditional head nurse. Today's (often rotating) charge nurse is a harried individual who usually carries a patient care assignment. This person bears little resemblance to the geographically stable and omnipresent head nurse who used to know all the patients, housestaff, and attendings and had patient safety as a mission, without other distractions. Nurses used to take pride in their role as protector, guarding the patient from physician and systemic errors; now they are more often in the loop of the errors as full participants. This is not their fault but rather the fault of a system that is too complex to do without more supervisory presence. If we can't or won't bring more supervision and coordination to the patient care experience, we should recommend that all patients be accompanied by a friend or family member who can at least ensure that orders and procedures are consistent with a preadmission care plan. For those lacking such a companion, one could be appointed from a volunteer pool.