Scarier than Halloween: Medical Mistakes

Posted: Oct 29, 2013
Views: 2720 - Comments: 6

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Halloween is coming up pretty soon, and it got me thinking about being scared. It happens a lot to me because I am a WIMP when it comes to scary things:

  • When I read a scary book at night I make the dog come to the bathroom with me so I’m not in there alone.
  • I started watching The Walking Dead at 11pm (in addition to easily scared apparently I’m also stupid) and then realized I needed to take the trash out to the curb. At midnight. I woke my princess dog up from a dead sleep and made her come outside with me so she could warn me of approaching zombies.
  • I paid money to go to a haunted house in college (again, stupid, but there were cute boys involved, I’m a sucker for a cute boy) and had sore muscles the next day from being so tense and squished into myself all evening. After we came out of the house and I finally relaxed, a couple of kids in black robes and masks came rushing at us and started screaming. I FLIPPED OUT. I hit the deck, covered my face and my friends had to literally drag me to the car.http://en.wikipedia.org/wiki/File:Halloween_Witch_2011.JPG
  • I watched the movie Poltergeist when I was way too young (during a sleepover, isn’t that how most bad decisions are made?) and to this day I can’t be in a dark room with static on the tv. Freaks me out.

I’m not known as the brave friend.

I started thinking about work too, and the last time I was scared at work. I’m talking sweating, heart rate 150, adrenaline. Was it the HBC dog that had four peripheral catheters and a different unit of blood going into each one? Autotransfusion. Awesome. Ummmmmm NO, That was FUN. Was it that super-angry cat that I needed to get out of the bottom kennel and somehow get drugs into? Nope. Again, kinda fun! The last time I was scared at work was because of my own stupid mistake. Thank goodness it was a stupid mistake, one that didn’t have any lasting effects on the patient, but it was something I did when I wasn’t paying enough attention to what I was doing.

When a mistake happens my first question is always, “Was it a training issue? What can we do differently in our training so this doesn’t happen again?” I also want to hear from the mistake-maker. I want to ask, “How did this happen? Not enough people on the floor to get the job done? Not sure how to do it? Unclear instructions, tired, overworked, scared, afraid to ask questions?” There are lots of reasons for mistakes. The part we need to focus on is: What are we doing to reduce the number of mistakes?

I personally have no problems sharing the dumb things that I do on an almost daily basis (things that have no effect on my patients), but we’re much less comfortable sharing the mistakes that do have an impact (big or small) on our patients. Is it fear of retaliation from doctors? Management? Owners? Are we afraid to break that trust? As awful as making a drastic mistake feels, it’s worse to hide it.

It’s important to let others learn from mistakes so we can learn collectively and move on. One of the best talks I attended at IVECCS was M&M rounds from criticalists, talking about horrible mistakes made in their hospitals. While it’s fascinating (in a very sick way) to hear what happened in these cases, it’s even more valuable to hear what they learned and how they changed to never EVER repeat that mistake.

Veterinary patient medical chart at DoveLewis with syringes, needles, and injectable drugs

Just because I’ve been doing this a long time doesn’t mean that I can’t accidently draw up the wrong amount, forget to highlight a treatment, forget to reduce the isoflurane, feed the fluid line backwards through an IV pump or forget to call an owner back. What’s important is how I move forward from those mistakes, how I change my ways to not repeat them. I rely on my coworkers to tell me when I’ve done something wrong, and I hope they feel the same way about me. I’m a note-taker, a triple-checker on the math, and a question-asker. After 14 years at DoveLewis I still ask questions. So far so good… I’d like to keep my scary moments reserved for haunted houses.

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Comments

Valwynn Williams's picture

Thanks Megan, for your candour and good humour. No one is exempt from mistakes .. . . we are all in this together, so let's learn from one another! Might I suggest to new grads one thing: Please cut down on the chatting. Let's take an interest in eachothers personal lives off the floor. When we hit the floor for our 12hour shift, let's focus on our patients and the details of our work in relative quiet. Clinics are noisy and busy enough without the distraction of chatting. Another thing: Use self-talk to focus yourself on the task-at-hand. Even if you have several patients that need you at the same time . . . focus on and carry-out one task at a time. Take notes: keep that little flip note-book with you and write down immediately verbal orders. AS WELL it's most important to VISUALIZE those orders on the chart. CONFIRM what the doctor is asking for and what is expected of you at that moment. Never stop asking questions of yourself or others (politely, of course :-) Even if they seem silly, or make you feel foolish. Better you feel foolish than have an irreversible situation with a patient. Quadruple check your arithmetic, especially in the waning hours of your shift, when you are most fatigued.

Finally, BE AFRAID of the drugs you administer to your patients. Let your fear of harming your patient motivate you to get it right and stay sharp. Develop your own failsafe strategies to avoid medical errors. Learn to be present in the moment and be the best you can be from start to finish of your shift. Thanks for letting me share my thoughts!

Megan Brashear's picture

Thanks for your comment Valwynn, so important. No matter how long or short we've been doing this job, no experience can replace pausing, thinking, repeating, and FOCUS. A little bit of fear can be a good thing!

Kyla Nelson's picture

Thanks for your comment Megan :-) Love your work and love all the videos @Dove. I'm enjoying following Dove's amazing work!

Valwynn Williams's picture

Love your work Megan! Thanks for taking the time to answer. Love all the videos! I'm very much enjoying following DoveLewis's amazing work!

Cynthia Fairchild 's picture

If this were social media, I would have to "like" this a gabillion times.
It's always good to have a healthy amount of fear when you have lives at stake. It takes a brave person to admit their mistakes and learn from them. Pride often gets in the way, I see that a lot, but learning how to approch a situation and make asking questions a standard is key. I see some techs, and even doctors, hesitate to ask, for fear of ridicule, seeming unitelligent, or whatever.... I will ask anyone and every one, even kennel, to check my work...
it's a learning process, especially in ER... I've been doing this almost 15years and I'm learning new things daily!

Sarah Harris's picture

Really well said Cynthia! I will always have more respect for someone who is humble enough to admit mistakes and avoids making excuses. We have to be able to realize that we are not perfect and know that errors will happen. Doing this will help us create an environment that limits errors by facilitating learning and creating a culture where asking questions is welcomed!