Friday, February 09, 2007

Mistakes

Let's start here: I've never killed anybody. Yes! Score one for the big guy. To the best of my knowledge I've never caused serious harm either. Here are some of the mistakes I've managed to make in the course of my career so far:
  • Informed a patient's parents that we would call them when their child was off the heart bypass machine and back in the intensive care unit. That went down like a lead balloon as the child was in fact having spinal surgery. Oops.

  • Gave a medication IV when it had been switched to oral.

  • Gave a larger than usual initial dose of adenosine due to making an assumption about its concentration which turned out to be incorrect.

  • Gave a medication that recently passed its expiry date.

  • Missed giving a charted medication due to rushing and not checking the chart carefully enough.

The reason I know I made those mistakes is that, where I didn't discover the problem myself, I was notified by the constant checking and cross-checking and reviewing of my colleagues. It's a given that humans are fallible, and that in an increasingly complex hospital world, we will screw up from time to time. The trick is to minimise how often that happens, not to make the really big mistakes, and to put measures into place that reduce the risk of them happening again.

I've caught any number of mistakes from both nurses and doctors. Some examples follow. In each case I can see exactly how the mistake was made, and I can imagine doing that myself given similar circumstances.
  • A ventilator's pressure release valve screwed in all the way, which would not allow excessive pressure to be vented to atmosphere.

  • A bag of IV fluids made up correctly for the unit's standard orders, but incorrectly for the particular patient who had other requirements.

  • A 'ten times the dose' charting error made by a tired registrar.

  • A ventilator set up 'backwards', with the expiratory limb plugged into the inspiratory flow outlet. Patient was ventilating fine but it confused the hell out of the humidifier.

  • An unnecessary medication prescribed by a consultant who made an assumption about the patient that turned out to be incorrect, based on a mis-reading of a fluid balance chart.

  • A dopamine infusion advertised as 5 mcg/kg/min by an anaesthetist that was in fact 10 mcg/kg/min. Sort of explained the extremely 'healthy' blood pressure we were getting.
I mention these not to try to sound clever, but to illustrate that the process works both ways. You make some mistakes, you catch some mistakes. There's a peculiar kind of ego-supression that has to go on in order to survive in this environment, where you swallow your pride and realise that you're not super-nurse or super-doc but rather a mere fallible mortal who gets it wrong some of the time.

I know that people who come into hospital would much rather believe that mistakes don't happen, but the truth is that little mistakes happen all the time. Big mistakes, thank god, are much rarer and (if you're careful, and lucky) tend to be the sort of thing you hear about but don't see.

The same themes recur throughout incident reports submitted when a mistake is made: haste. Overwork. Overtiredness. Inexperience. The risks inherent in understaffing are well documented. A less popular admission among hospital staff is that, even under the best circumstances, errors will still occur.
Posted by PaedsRN at 8:54 AM
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