Bits 'N Pieces Newsletter


January 2019 Print

President's Message

Kristen L. Rifenbark, MSA, CPHRM, CPPS, FASHRM, 2018-2019 MSHRM President

As we ring in this New Year, I am reminded of how much I have to be grateful for.

I’m grateful for the gifts that MSHRM has bestowed upon me. Much of the knowledge I have about risk management has come directly through MSHRM or one of my MSHRM colleagues. I cannot think of any of my co-workers who can say the same about their professional organizations. I am grateful for the expertise that MSHRM envelops, embraces and disseminates to each of us.

I am grateful for the MSHRM sponsors who so graciously give. Many, but not all, who donate to MSHRM realize the tremendous impact their donation creates. Michigan is often at the forefront of patient safety- and risk management-related initiatives, and every dollar and volunteer hour makes that possible. Speaking of volunteers, I am grateful for the 83 volunteers who serve on the various MSHRM committees. I cannot even imagine where MSHRM would be without the service that so many provide year after year!

I am also grateful for the friendships that I have forged through MSHRM. I now know people throughout our great state. I love meeting up with them during our meetings in the spring, early summer and fall.

As I prepare for the Winter Webinar, I am again grateful for what I anticipate will be another great education opportunity from MSHRM.

I am a firm believer that gratefulness can only truly be expressed by action, not simply words. So while I can thank everyone for their contributions, the best expression of my gratitude is to act upon that gratitude, and I ask you to consider the same. Volunteer. Donate. Share. Teach. Whatever your abilities and whatever your capacity, do something. Whether it be volunteering on a committee, or teaching a new safety principle to your organization, I urge you to pay-it-forward. Knowing you, the MSHRM membership, it won’t be hard …

Happy 40th Anniversary, MSHRM!

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Review of Appellate Decision Kelly v Ononuju, DO et al

Prepared by José Brown, Government Issues Co-Chair


This was an appeal by Defendant Downs Pharmacy, for an order denying summary disposition. The appeals court reverses and rules in favor of Defendant stating that it would be "illogical" to impose a duty on the pharmacist with respect to a third party.


Whether the Defendant pharmacy owed a duty to Plaintiffs to protect the vehicle occupants from a third party.


Dr. Ononuju prescribed Fentanyl patches to patient Kevin Haynes to manage chronic pain. Dr. Ononuju noted that Haynes had a history of narcotics dependency and was currently using drugs. Dr. Ononuju had diagnosed him with drug abuse. Haynes would typically fill his prescriptions at Defendants pharmacy, which was located in the same building as Dr. Ononuju's office. In March of 2013, Haynes filled a prescription for Fentanyl patches at Defendant's Pharmacy. He placed a patch in his mouth, contrary to intended use, and then drove his vehicle across the centerline of the road killing two sisters who were passengers in a vehicle.

Legal Analysis

In its review of the case, the appellate court noted they had already addressed the duty of a pharmacy toward a patient:

The general rule is that a pharmacist is not liable for damages resulting from a correctly filled prescription:

  • Stebbins v Concord  Wrigley Drugs,  Inc., 164 Mich App 204

No duty to warn a patient of possible side effects on a properly filled prescription where neither the physican or manufacturer has required that any warning be given to the patient by the pharmacist.

  • Adkin v Mong, 168 Mich App 726

A pharmacist has a duty to fill lawful prescriptions properly and will not generally  be held liable when he or she correctly fills a prescription that was issued by a licensed physician. A pharmacist does not have a legal duty to monitor and intervene with a customer's reliance on drugs prescribed by a licensed treating physician.

  • Kintigh v Abbott, 200 Mich App 92

A pharmacy owed Plaintiff no duty to discover his addicted status. Without knowledge of Plaintiffs addicted status, no duty to refuse to sell  to him.

The only case noted by the court imposing a duty on a pharmacist:

  • Baker v Arbor Drugs, Inc., 215 Mich App 198

Plaintiff suffered a stroke and died as a result of the pharmacy mixing two incompatible prescriptions. The court found that the defendant voluntarily assumed a duty to plaintiff since it used its drug monitoring computer program to check for prescription incompatibilities.

Plaintiffs rely on two cases involving physicians treating individuals who then later injured or killed third parties as a result of alleged improper treatment:

  • Welke v. Kuzilla, 144 Mich App 245

The court limited its holding to the narrow facts of the case

  • Duvall v Goldin, 139 Mich App 342

The court found a duty to a third party due to a breach in the standard of care in the physician-patient relationship.


Michigan case law does not allow for the imposition of a duty with the facts of this case. The court did not address whether a duty towards Plaintiffs would exist if Defendant had knowledge of Hayne's addiction. The court distinguished this case from Welke and Duvall because the Defendant was not under a duty to monitor Hayne's use of Fentanyl.

There was a concurring opinion by Tukel, J, where he joined the majority that generally, pharmacists have no potential liability to customers or third parties who fill a facially valid prescription. However, he states that both federal and state law impose an obligation on pharmacists to independently consider whether a prescription for a controlled substance has been issued in good faith and for legitimate purpose.

Federal rules require a "corresponding responsibility" of the pharmacist to consider the propriety of a prescription and state law requires dispensing of controlled substances in "good faith"  guided by a set of non-exclusive factors.

Click here to access the Court of Appeals opinion and concurrence.

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Vendor Sponsorship & Exhibition Opportunities

MSHRM’s Vendor Sponsorship Program offers the ideal opportunity to connect with healthcare leaders from across Michigan.

Through sponsorship, your organization will benefit from networking opportunities, key visibility, and be honored for enabling MSHRM to provide valuable educational resources and programs at an affordable cost for our members and guests. Your contribution will help provide safer healthcare across Michigan!

Click here for details of our suggested sponsor levels and opportunities. Contact Nichole Dennis, Chapter Administrator, at [email protected] or 616.755.8488 with any questions.

Thank you to the following organizations for continued support of MSHRM.


($2,750 and higher)

  • Aon
  • Coverys
  • Kitch Attorneys & Counselors
  • Michigan Professional Insurance Exchange (MPIE)
  • Smith Haughey Rice & Roegge


($500 to $1,749)

  • Grant Settlements, LLC
  • Michigan Health & Hospital Association
  • RCO Law


($200 to $499)

  • Duggan & Krueger, LLC
  • Schoolcraft Memorial Hospital

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Fellow of the American Society for Healthcare Risk Management (FASHRM):

Director, Clinical Loss Control, Trinity Health

To achieve ASHRM designations of Distinguished Fellow or Fellow, ASHRM members must meet specific criteria for academic/professional designation, continuing education, risk management employment experience and contributions to the field of healthcare risk management through leadership, lecturing and publishing. Each candidate must submit a comprehensive application with documentation of their achievements to meet either the DFASHRM or FASHRM criteria.  The ASHRM Board reviews applications for compliance with the criteria and grants designations to successful applicants.

Congratulations to Karen on your achievement!!!

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Doing Stress Well

This is the first of two articles on stress management. In this article, Ron Culberson discusses the stress process. In the second article, he describes how to use humor to manage this process.

After five weeks of needles, bedpans, and green hospital Jello (not in that order) and six weeks in a leg-hip-leg cast, I had finally graduated to crutches. The final step of my recovery from a compound fracture of my femur was physical therapy. For a ten year old, it had been a long, hard road and I wanted to get back to kicking my sisters.

The physical therapist, Dr. Ed Hill, resembled a bouncer on steroids. He wore a tight t-shirt with rolled up sleeves, had a large tattoo of the Navy insignia on his bicep, and always gnawed on the stub of a cigar. It was 1971, before smoking and cruelty were prohibited in hospitals. Dr. Hill instructed me to lie on the exam table and then politely asked me to bend my leg as much as I could. After being immobile for 11 weeks, my leg had forgotten how to bend. I grunted and groaned and achieved approximately one degree of movement.

“You can do better than that,” he said.

“No. That’s about it.” I said, smiling.

Before I knew it, he punched me in the stomach and instinctively, I drew both knees to my chest. My leg screamed in pain. I screamed in fear.

“Good,” he said, “I knew you could do it.”

On subsequent visits to see Dr. Hill, about a mile from the hospital, I would notice a pronounced tremor in my hands and sweat on my upper lip. Luckily, today, at age 48, the nightmares have almost completely disappeared. But physical therapists still scare me more than just about anything...except clowns.

Perhaps this was Dr. Hill’s “normal” technique. I suspect that wasn’t and instead, he had experienced some stress in his life and it was leaking out in his work. So, ultimately, his stress became my stress. Does this sound familiar? Have you seen it in yourself, your family, or your coworkers? That’s because it’s normal to experience stress and while you can’t change what happens to you, you have complete control over what you do in response to stress. Humor can help - as long as you understand the context of stress itself.

As a social worker, I am well versed in a variety of stress management techniques. From relaxation to meditation to hypnosis, drugs and heavy drinking, I’ve tried it all. The challenge, however, is that most healthy stress management techniques require laser clear focus and regular practice. To be honest, I have never been good at the whole focus thing because I am too easily distracted. For instance, if I need to relax and try to visualize my “happy place” by imagining a sunny beach or a mountain cabin, my mind quickly begins to wander and before I know it, I’m watching a shark attack or a scene from Deliverance in my new very unhappy place.

Humor, on the other hand, is a great way to manage stress and for me, it’s a much easier technique to use on a consistent basis. Even though it to requires focus and regular practice, it’s a more fun and makes the whole process more enjoyable. But before we get into the specific humor techniques, it is important to understand this beast known as “stress” first.

Did you know that stress is not inherently inherent? In other words, the stressor (that thing that causes the stress) is not in and of itself stressful. I know, it sounds crazy but work with me on this one. You see, our cognitive interpretation of the stressor and then our subsequent reaction to it are what cause the stress we experience – not the stressor itself. Maybe a visual will help. Here is the formula for I’m describing:

IMPACT OF STRESS = Stressor + Our Interpretation + Our Reaction + How We Cope

So we experience stress when the formula plays out like this:

STRESS = Stressor + Negative Interpretation + Negative Reaction + Bad Coping Skills

To illustrate this further, here are two examples:

1. Suppose your spouse suggests that you could lose a few pounds. Immediately, the insecurities of your body image rise to the surface and you hear your mother’s voice from your childhood saying, “You need to go on a diet” or “Why are you so lazy?” or “You’re wearing that?” You react with anger, but since anger is not a pleasant nor socially acceptable emotion, you turn the anger inwards and become depressed. And whenever you’re depressed what do you do? You eat – which causes guilt, stress and more eating. 

2. If on the other hand…someone asks why your hair is green and you know full well that your hair is not green; you assume the person is mentally imbalanced and disregard his/her comment immediately. Once it’s disregarded, it’s gone from your mind, you have no reaction whatsoever and experience no stress.

In the first example, the interpretation of what the comment means or represents leads to deeper issues on which you then focus. That leads to stress. If, instead, you did not “read” too much into the comment, you would experience less stress. In the second example, you have no emotional connection to the comment and thus no stress reaction. The interpretation is critical to the stress we experience…or don’t.

I am not suggesting that you disconnect completely from any stressor. However, the more you focus on the negative aspects of any situation, the more you will experience stress. Also, it’s important to understand that some major life stresses are inherently stressful. The death of a loved one, a serious illness, or when your mother made you wear that ridiculous flower outfit for the school assembly when you were in 7th grade and were already concerned about what people thought of you are probably going to cause stress. That last example is just a hypothetical one.

Once we recognize that there are several steps along the stress pathway that can be stopped, then we can look for ways to use humor as the brakes. In Part II of this topic, we’ll take a look into the interventions more specifically.

© 2017 Ron Culberson. Shared with permission.

Ron Culberson, MSW, CSP, CPAE is a speaker, humorist, and author of four books including Do it Well. Make it Fun. The Key to Success in Life, Death, and Almost Everything in Between. His mission is to change the workplace culture so that organizations are more productive and staff are more content. He shows people how to have more FUN while preserving the integrity of the work they do and the lives they lead. For more information, visit

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Education Key Takeaways

MSHRM’s Fall Program titled, Controlling Risk: Behavioral Situations, took place on October 2, 2018 at the Henry Center in Lansing. 124 people were in attendance. For those not able to participate, following are the key takeaways from the informative presentations.

Obligations to Preserve Electronic Data from Personal Devices of Employees:  How, When and Why?  Measures to Prevent the Conduct – Orientation, Risk Management, Legal Counsel

Jean Ann Sieler, JD

Key issues when investigating:

- Goal is to preserve data

- Limited investigation—HIPAA analysis

- Delete or remediate data—backup

What to do when you need to view an employee phone’s contents?

- Seize phone—not really practical

- Outsource to forensic cell phone extraction company (best option)

  • Can send the phone out, rush service ~$1000
  • Onsite extraction—some newer phones do not allow this
  • Total price $3000-3500 depending on phone type

- Use an app to store texts with dates & times—not adequate, need an expert to decode

- Screenshots—free

Include in employee orientation that staff may be subject to access/extract cell phone memory, they assume this risk and lose right of privacy. Have an acceptable use policy.

Michigan Health Professional Licensing Defense

Daniel Shirey, JD

Commencement of a Licensing Action

- Anyone may file a written allegation

- A licensee must report another licensee if there is knowledge of a violation of the Public Health Code, impairment, etc. (with limited exceptions)

- Licensees must report themselves for a criminal conviction (e.g., DUI), sister state actions, etc., within 30 days


- Summary suspension, suspension, revocation

- Limited license

- Other restrictions


- Fine up to $250,000 ($25,000 now required if violation results in patient death)

- Probation

- Reprimand

- Practice monitor

Compliance conference

Administrative hearing

Michigan Healthcare Workplace Violence Bills

Richard Joppich, JD

HB 6203

- Modifies existing criminal law

- Adds healthcare professionals and medical volunteers

- Felony to assault, batter, wound, or endanger

- 2 years and/or $2,000 fine

- Elevation of penalties dependent on level of harm

HB 6204—activates the Michigan Rules of Criminal Procedure as applicable to any criminal charge brought under the HB 6203

Creating a Safe Environment for ED Patients and Caregivers

Tammy Banker, MSN, RN, NE-BC and Jerry Durmond

Goal of hospital system was to create a safe space for behavioral health patients seeing acute care in the ED

Features of this space include:

- Anti-ligature components

- Weapon free

- Tamper resistant

- TV and light controlled options

- Barricade issued (doors with very specific hardware)

- Bathroom design

- Video monitoring in place with Security overseeing the patients

Patient flow was processed mapped

Included support departments to maintain safety

Visited other facilities to learn from their journeys

Opioids: An American Epidemic

Michael Goetz

Overview of opioid crisis

- Michigan Rx for opioids is 37% above national average

- Opioid deaths 5x higher in 2016 compared to 1999


- Synthetic opioid

- 10,000 x more potent than morphine

U-47700 aka pinky or pink, U4

- Often mixed with other opioids to potentiate

- More potent that morphine

Neurontin misuse now being addressed with education for providers and consumers

Care of Psychiatric Patients in Community Hospitals: Changes, Challenges and Strategies

Solveig Dittmann, RN, BA, BSN, CPHRM

Issues with care of behavioral health patients in hospitals


- Michigan has only 15% of the needed beds for our population, 4th from the bottom

- Causes are multifaceted - closure of free standing facilities, lack of appropriately trained caregivers

Patient care and risk management

- Environmental strategies - security, specialized units, safe rooms, cameras, panic buttons, multiple exits, shelter in place areas

- Interventional strategies - MSE, med reconciliation, suicide risk assessment, nicotine replacement, diversion activities

- Educational - training for all in de-escalation, least-restrictive alternatives, frequent practice, self-awareness (body language, triggers)

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