Saturday, January 30, 2010

Enough! Hidden Hazards that Impair Safety

This morning my husband, my son, an exchange student and his host brother are holed up in what my mom would call a "no tell mo-tel" 30 miles south of snowy Nashville where I am waiting to greet them with tickets to tonight's Thrashers-Predators game. The boys gave up trying to complete the drive from Atlanta last evening when my husband, who grew up in Canada, said, "Enough." And not a lot more.

Unpredictable things that derail what we intend to do are annoying, and they can be dangerous. Like icy patches hidden under the snow, they're often hidden. Hazards are on my mind today.

On a larger scale, I've been reflecting about hidden places where safety gets derailed ever since a link to an article in the UK hit my Tweet stream last week. The headline and the original tweet used precious characters to say this: "Nurses who overdosed two Heartlands Hospital cancer patients escape punishment by professional body." The re-tweeted version that came to me included these words: "Sometimes sorry is not enough."

Based on the published account of these errors, the tragic events that resulted in the deaths of two patients did not happen because the nurses and physician intended to harm them. Rather, the processes they used to provide care on a regular basis failed when they were subjected to a drug's hidden hazard: Safe dosing of the drug involved, amphotericin, depends upon whether the specific product on hand is in a conventional or liposomal formulation.

The Institute for Safe Medication Practices defines a series of routine checks and balances that should be in place in clinical settings where amphotericin is used. Differentiating--calling out in a way that is obvious and unmistakable to all clinicians who prescribe, dispense, and administer drugs with liposomal formulations--is one of the strategies necessary to prevent these errors. It's also worth noting that liposomal formulations of drugs are part of a group designated as "High Alert Medications" so-called because they are highly likely to cause grave harm when used in error.

The process the clinicians used the day two people in the UK died failed because it was insufficient to prevent or detect a potentially lethal error that was set in motion. The nurses told the professional board that they were "very sorry," words that seem to have fueled the grief of the families and caused some in the global community to judge them, too.

"I'm sorry," no matter how sincerely felt or expressed, does not restore the dead to the living. That is not the purpose of expressing remorse nor for accepting an apology. The survivors of a terrible tragedy caused by medical error must be supported in how they choose to proceed, dealing with the unwelcome life-altering changes such events hoist upon them. Survivors must be free to accept or not accept expressions of regret (although many find  sincere apologies by individual clinicians and organizational leaders lessen their burdens).

But how we treat the people at the "sharp end" of a tragic system failure is ultimately a measure of safety culture. And it's a place where where good people (including many patient safety experts and healthcare professionals) slip on a hidden hazard. Saying that the nurses involved in this error "escape punishment" suggests they deserve punishment. And "sometimes sorry is not enough" leaves me scratching my head. What would be enough?
The needs of those intimately involved in errors that cause grave harm have remained unexplored, hidden. Don't miss the opportunity to learn more about this error of omission in TRUST: Five Rights of the Second Victim. (Click this [link] to reach the TMIT Articles homepage where a pdf of "Trust: Five Rights of the Second Victim" can be downloaded.) And on Thursday, 2/4 the Institute for Healthcare Improvement is hosting Adverse Events and their Aftermath: SOS from Clinicians, a conversation facilitated by patient safety leaders from the professional and patient communities.

Postscript: You can access a recording of the IHI webcast  mentioned above by clicking this [Link].


Anonymous said...

Thanks Barb for continuing to make this insane culture of perfection (and it's consequences) known.

Half a year later, things in my residency program are different in some ways. I've made some embarrassing (but not dangerous, yet!) big errors - but I knew how to handle it and those around me did too. We are still tip-toeing on eggshells around certain topics in our residency program and our first formal 'dealing with errors' session will occur in March.

Mistakes are still scary as hell, but knowing when/where they commonly occur, and teaching people how to handle them makes a great difference to patients' and health care providers' health.

Susan McCabe, RN said...

@susanlindsey we'd like to hope that those with a calling to be a healthcare provider have high ethical standards. my experience is that most of us hold ourselves accountable. unfortunately, punitive cultures may be a deterrent to practice and variance reporting. it's only by well defined processes that clearly outline the consequences that we can practice not with the hope of impunity but with the assurance of positive change and continued recruitment of the highest quality providers.

JosieKingFoundation said...

thanks for a great, thoughtful post on this topic, barbara. i, too, was left scratching my head at the poorly chosen headline "sometimes sorry is not enough". disclosure advocates are not saying, "the apology is all we care about." disclosure is the first step in making a safer health care system for us all. and a safer health care system is also one that doesn't spend inordinate amounts of time and energy pointing the finger of blame on individuals working in faulty systems.

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