This weekend Dr Helgi (@TraumaGasDoc on Twitter) published a post with an example of wrong-site surgery (where the wrong part of the body is operated on), and how this experience changed safety procedures within his hospital. Fortunately the patient needed surgery on both feet, although each was to have been done separately, so operating on the ‘wrong’ one in this case was not disastrous. In the end both feet were operated on during the same surgery and the patient made a full recovery.
The post clearly shows that there was not a single event that led to this situation, but a series of events that, in retrospect, could have been used to spot a problem about to happen. Dr Helgi’s medical director gave him permission to publish the (anonymised) information in order to encourage wider learning beyond just their hospital. At the time of writing the post has had over 10,000 hits and there’s been a lot of discussion on Twitter and encouragement for others to share examples too (where appropriate).
You can read his post here: ‘Wrongfooted‘
In response to that, Dermot O’Riordan (@dermotor on Twitter) shared an almost identical example from his own hospital – noting that despite reporting the incident through official channels an opportunity for wider learning (beyond his hospital) seems to have been missed given that their own patient’s experiences hadn’t prevented Dr Helgi’s patient from having the same wrong-site surgery.
“I did want to publicise the incident but at that stage it was not the norm and providers seemed only to discuss matters in public if it got out. Very few, if any were being proactive and open.
I was aware of the power of Twitter and I did discretely hint that we had had issues and sought advice, in a stressful time, from colleagues. I was reluctant to be totally open. I am followed by quite a number of journalists (local and national) and to be honest I feared the reputational risk of talking about a Never Event*. There were also concerns about patient (and staff) confidentiality. Unfortunately the overwhelming atmosphere surrounding Never Events is that there is something wrong in the organisation.
In a number of fora I have publicly pointed out that the system seems more interested in what we as an organisation have done and to hold us to account. I have seen precious little effort to disseminate the learning.“
You can read his post here: ‘Failing to Learn‘.
Sharing errors can be a difficult thing to do and one of CHI+MED’s projects is Errordiary, a tool to enable people to share examples of everyday error.
Although the end result is very different the thought processes behind forgetting your keys or forgetting to give a patient medication are fairly similar so we can learn a lot about different types of errors from the everyday ones that are easier to share.
*A ‘never event’ is shorthand for an event that should never happen, although clearly they occasionally do. Here is the current list of never events for 2012-2013.