I will be more careful in the future is not a solution to improving patient safety.
Chapter 8 describes the impact on frontline workers when things go wrong.
A few years after my own personal experience of error, I carried out a retrospective investigation in order to finally understand why it happened. I now know that rather than being solely down to individual performance that there were a number of small moments or incidents during my shift that led me to miscalculate the drug; the constant distractions, automaticity, routine practice as a norm not recognised to be unsafe, being interrupted mid task, combined with my sleep deprivation all contributed to the drug error.
My response was that I will try harder, that I will not make any more errors but this perpetuates the myth of perfection.
We all need to accept the fact that people, processes and equipment will fail. By understanding this, organisations can focus on developing ways in which to prevent and plan for these failures. If instead we simply punish people when they make errors we will not learn about the underlying conditions that may have caused the error. When staff are fearful of repercussions and blame it hinders them from sharing their concerns and speaking up when things go wrong.
What we need is to all talk to each other when things go wrong, for example about what happened, and about what we all think could be done differently. To have conversations that help people feel confident to speak out when things go wrong. What we also need to do is learn to talk to patients and their families; to have conversations one human being to another.
If we had these conversations people may learn more about what they can do to make their care safer and who knows how many patients could be saved from harm if we did this.
In this chapter I explore the story of Bob Ebeling who was one of the engineers working on the shuttle Challenger 30 years ago – Bob has since died. but his story is extremely moving. Bob talked for the first time publically in a radio interview to coincide with the 30 year anniversary. He talks about how he was simply not listened to but that since that tragic day, Bob blamed himself. He always wondered whether he could have done more. That day changed him, he became steeped in his own grief, despondent and withdrawn and he quit his job. If you listen to the recording you can hear his voice; it is low, quiet and heavy with sadness as recalled the day and described his three decades of guilt.
While this story relates to space travel, there are strong synergies with the way healthcare practitioners have across the centuries tried to speak out and not been listened to. If Bob had been listened to, he may have been able to prevent the death of seven astronauts.
Those affected by error live with the guilt for the rest of their lives. They are profoundly and forever affected by these events. We have seen how people can experience guilt, anxiety, depression, and more. They find themselves reliving the event days, weeks, months and sometimes years later. The devastation can lead to their lives unravelling. Evidence suggests that unsupported health workers may also change their place of work or leave and even some leave the career altogether. Well-trained, caring, experienced nurses and doctors are moving on, either to another hospital or another career altogether.
We need to care for people; be kind to them, support them to come to terms with what went on and never be judgmental. If people could talk to each other about these experiences it would allow others to come forward to share. Every healthcare facility should provide an ‘after event’ duty of care to all; a function that supports patients and their relatives and staff when things go wrong.
Kimberley was, just like me, a nurse who worked in PICU although her story was 20 years later. As a result of a ‘ten times the dose incident’ one of the children in her care died. A doctor instructed Kimberley to administer 140 milligrams of calcium chloride to her patient, a 9 month old infant. She worked out the dosage in her head because she had administered calcium chloride hundreds of times. She in error miscalculated and drew up ten times the dose prescribed.
I read Kimberley’s interview. She said she had I messed up, that she was talking to someone while drawing it up and she told them that she would be more careful in the future. Almost immediately after the interview, Kimberley was escorted off the premises. I cannot imagine how that must have felt. Kimberley was not a bad person. She loved her job, she loved her patients. All of a sudden she was isolated from the job, her colleagues and the hospital where she had worked for over 24 years. We are told that she drove home panicking about what happened. You can see she felt she was personally and solely culpable for this incident. She also gave us clues as to why the incident happened; distraction, automaticity, calculating in her head. I will be more careful in the future is not a recommendation for sustained change.
Four days later the child died and shortly after that Kimberley was fired. She struggled with the death of the patient and the loss of the career she loved. Sadly she never got over this incident and seven months after she was walked off the premises she committed suicide. In Kimberley’s case, one of the employees said they felt that people were afraid to admit their mistakes, based on what happened to Kimberley. They suggested that people didn’t admit mistakes because they were afraid of losing their jobs (Kliff 2016). It is vital in the memory of healthcare workers like Kimberley that healthcare providers take care of their healthcare workers – they owe a duty of care not only to patients and their families but the people who care for them.
Kliff S (2016) Fatal mistakes [online] available at vox.com