Scarier than Halloween: Medical Mistakes

Posted: Oct 29, 2013
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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.
  • 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.