Practical problems: Learning from mistakes

Some people hold the view that to err is human, unless you are a doctor. Julie Wilson argues that all doctors can make mistakes, the key is to learn from them

No-one is a perfect doctor; mistakes don’t just happen in our home lives, they can happen at work

Ask yourself: “Have you made any mistakes today?” If your immediate thoughts are along the lines of: “Of course not. I’m a good doctor and just completed years of training, mistakes are caused by carelessness not by good doctors”, you may be mistaken, so read on. No-one is a perfect doctor; mistakes don’t just happen in our home lives, they can happen at work. If a plumber put a nail through a pipe, it would cause a mess, but no-one would die. However if a doctor makes a mistake, a person could die – it is a risky occupation.

So think again: “Have you made a mistake recently in your everyday life?” Ever put unleaded petrol into a diesel-fuelled car? If yes, then you are not alone. In 2006, more than 120,000 people called out a breakdown service after filling up their cars with the wrong type of fuel. Remember Wayne Rooney had to be rescued on the motorway when he put the wrong fuel in Colleen’s Range Rover and the mistake cost him more than £6,000.

So why do we make these errors?

it is important that defences are in place to make these mistakes due to human fallibility less likely

According to Mike O’Leary, ex-chief executive of British Airways: “Accidents rarely happen without warning. The sequence of failure and mistakes that cause an accident may be unique, but the individual failures and mistakes rarely are.” His sentiments are echoed in the work of renowned cognitive psychologist and expert on error Dr James Reason. He began to explore human error after he put cat food in his teapot, while making tea and feeding his cat. The two components got mixed up; both the teapot and the cat’s feeding dish afforded the same opportunity - putting stuff in. Dr Reason created the “Swiss cheese” model to explain human fallibility, which is made up of two approaches: the active (person) and the latent (system).1

  • Active failures – the unsafe acts committed by people who are in direct contact with the patient or system. They take a variety of forms: slips, lapses, fumbles, mistakes, and procedural violations.
  • Latent conditions – arise from decisions made by management, etc, and these decisions have the potential for introducing failure into the system. For example, these include time pressure, understaffing and inadequate training.

The “Swiss cheese” model illustrates the trajectory of an accident. The holes in the Swiss cheese represent the failures in the system’s defences that allow a hazard to pass through. So error is a combination of human and system failures. Even the best of us make mistakes, so it is important that defences are in place to make these mistakes due to human fallibility less likely.

Scenario

Vials of lasix and potassium chloride are stored in containers next to each other in a treatment room. A patient goes into congestive cardiac failure. The doctor rushes into the treatment room to obtain a vial of lasix. In his hurry he selects potassium chloride and administers it to the patient. The patient dies. What are the “Swiss cheese” holes in this scenario?

  • Active holes – tired doctor, working nights, third night in a row, feeling unwell, stressed.
  • Latent holes – vials of medication similar, small writing, stored next to each other in the open containers in the treatment room, not labelled on containers, poor organisation of doctors’ rota.

Incident reporting system

Incident reporting has proved to be a useful tool in preventing error in high-risk industries, such as aviation, nuclear and petro-chemical industries. It has increased investment in the development of proactive and reactive safety systems. If an aviation incident occurs it is reported, investigated and lessons are learnt. Are you aware of the incident reporting system at your hospital?

Reporting when things go wrong is essential, as it explores the underlying causes of patient safety incidents. NHS organisations should have a systematic approach where staff know what type of incidents to report, what information is required and how to learn from it. Staff should feel they can report incidents without the fear of personal reprimand. A positive patient safety culture is one that has open communication, mutual trust, shared perceptions of the importance of safety and confidence in the efficacy of preventative measures.

Learning from patient safety incidents

The best doctors openly admit to making mistakes and see the process as a learning tool

Patient safety incidents need to be shared to prevent them happening again. The National Patient Safety Agency (NPSA) was set up in 2001 to coordinate efforts to report and learn from mistakes. It collects and analyses reports of patient safety incidents received from NHS staff. As well as making sure errors are reported in the first place, the NPSA is trying to promote an open and fair culture in the NHS, encouraging all healthcare staff and patients to report incidents.

During the last five years, the NPSA has received more than 2.7 million reports of patient safety incidents.2 The NPSA anaylses these reports and creates safety alerts actions and Rapid Response reports. An analysis of patient safety incidents reported to the NPSA between July 2007 and June 2008 showed that 589,043 incidents were reported from acute/general hospital settings, 73% of the total received for that period.3

What human factors can lead to mistakes?

  • Fatigue (sleep deprivation)
  • Hunger – long lapses between food/drink
  • Lack of concentration
  • Interruptions
  • Distractions
  • Lack of training
  • Lack of information
  • Unfamiliar with place of work (different room, new ward, etc)
  • Other – illness, under influence of drugs, alcohol, etc

So what have we learned?

All doctors make mistakes, hopefully minor ones. What’s important is being honest, owning up and reporting the mistakes so that lessons can be learned. The best doctors openly admit to making mistakes and see the process as a learning tool. Prepare yourself by finding out about the reporting system at your hospital, and read NPSA safety alerts. Patient and staff safety is essential for good quality care; let’s not forget that we are all patients too!

Julie Wilson is an experienced risk manager at MPS, with more than 20 years’ experience tackling risk in health settings.

References

1. Reason, J. Human Error: Models and Management, BMJ, (2000) 320:768-770
2. Department of Health, Safety First: a Report for Patients, Clinicians and Healthcare Managers, (2006)
3. NPSA, Reporting and Learning System Quarterly Data Summary (2008) – www.npsa.nhs.uk

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