Following on from last week’s post “Two examples of wrong-site surgery shared this weekend via social media“…
Errordiary is a project to get people understanding error better. By collecting examples of everyday error it highlights very clearly that we all make mistakes (typos, forgetting keys). Even though everyone understands this, sometimes we forget in medicine and blame people inappropriately.
No amount of training could stop me from accidentally mis-typing a letter when using a computer keyboard. Touch-typists generally know when the wrong letter’s been typed, others might check their text for errors at the end of a paragraph. Helpfully computer and software manufacturers have included things like a delete key and spell checkers – errors are an accepted and understood part of computer / keyboard use and word processing, and the system introduces solutions to help users recover from these errors.
The CHI+MED project is looking at something similar, but in the field of medical error. Part of our work involves researching what changes to the ways in which infusion pumps are designed (and tested, purchased, used etc) could help to make them more resilient to error (where a mistyped number or decimal point in the wrong place could be harmful or even fatal). You can get an idea of the full range of things we’re looking at from our list of publications.
When a serious medical error happens it is a hugely stressful experience for all involved. Sometimes responses have included blaming whoever was closest to the mistake and sacking or retraining them. As you’ll see in the example later in this Storify (from @TraumaGasDoc) it can take a series of small events to lead to a potentially serious problem (fortunately this one has a happy outcome) and clearly no-one person was at fault.
Sometimes retraining is appropriate but increasingly people are looking at other aspects of ‘the system’ to see where there are opportunities to bolster resilience to potential errors, reducing their effect. In other words, using errors as a learning opportunity.
Errordiary lets people share examples of everyday error – most people are very happy to share non-work-related errors, even when they might naturally be cautious about talking about more serious ones. Examples of errors collected through Errordiary can be used in understanding the thinking processes behind them (forgetting keys and forgetting to give a patient medication are examples of similar errors).
While chatting about the launch of the new Errordiary competition, which runs for three months, I asked CHI+MED’s Dr Dom Furniss to share, via Twitter, some other ways the tool has been used, when talking to healthcare professionals.
Here’s an example of one of the tweets collected by Errordiary. I think you can see what went wrong here…
“Man standing outside British Library on phone: “Where’s the British *Museum* then?“
Resilience strategies are things that people develop to reduce the risk of making an error, or reducing its effect. Hopefully my neighbour checks her keys before leaving the house but if not she at least knows that I have her spare set.
I asked Dom for more information about the red trays (I suppose you could read his tweet as there being patients who eat red trays, and need help doing so, but that’s not what he meant!) and he pointed me to an earlier tweet which had also been captured on Errordiary.
This (below) is the original tweet, if you click on the timestamp [Wed, Jun 13 2013] you can see the conversation that Dom and Jay (@RareToWellDone) had.
Then I spotted, thanks to a retweet by Dom, that @TraumaGasDoc (Dr Helgi) would be posting about a recent medical incident and that permission had been given in order to encourage wider learning.
Here’s @TraumaGasDoc‘s report (below). The patient had the wrong foot operated on however, fortunately, both feet required surgery. Although the plan had been to operate on them separately the decision was made to continue the operation and complete the procedure on both feet. Happily the patient made a full recovery and the story has been shared more widely ‘to extend learning beyond our own hospital’.
All wrong-site surgical procedures are reported through official channels but as you’ll see from the second post (below), inspired by ‘Wrongfooted’, although efforts are made to ensure that the hospital now has procedures in place to prevent this from happening again (ie learning from its own error)… there’s no guarantee that this information will be picked up and used by others to guard against the same thing happening in another hospital.
Previously published on Storify by Jo Brodie.