High reliability in healthcare: A personal failure
In his follow-up to last edition’s article on high reliability organisations, Dr Dan Cohen revisits a personal experience that formed part of his own steep learning curve
With a steadily increasing focus on safety and risk aversion in the healthcare industry, much attention, appropriately, has focused on the stories that patients and family members have shared about their experiences. We have learned much, although in some instances, especially early on, we may have been reluctant to listen.
Sadly, in my view, we have not always equally valued the stories that clinicians may tell about their own experiences, challenges, and even their personal needs and shortcomings. As an example, I would like to ‘fillet’ myself and reveal a personal story that has affected me throughout my career. This is a story of multiple system and personal failures, fortunately embellished by transparency and honest disclosure long before these became everyday terms in our patient safety vernacular.
A, a ten-month-old girl, was admitted to an internationally prominent children’s hospital at the weekend for evaluation of a kidney mass, likely a Wilms’ Tumour, a highly curable childhood cancer.
I was the paediatric oncology fellow (senior registrar) covering the service for the weekend.
This institution’s Wilms’ Tumour protocol required the oncology fellow to administer Actinomycin-D intravenously as soon as the renal vein had been clamped at the time of surgical removal of the tumour. I wrote the orders correctly and legibly using our standard double-check process and then things became complicated…
In addition to covering the inpatient oncology service (about 25 beds in this large centre), I had additional weekend obligations for the outpatient clinic and a two-bed bone marrow transplant unit located in different, though adjacent, hospitals. Usually this multiple coverage obligation was not a problem, but on this particular weekend, two children with leukaemia were to receive outpatient L-asparaginase chemotherapy, and I had to be present in the clinic because of the substantial risk of allergic anaphylactic reactions.
I could not be in clinic and the operating theatre at the same time. Recognising this dilemma, I arranged for the anaesthesiologist on A’s case to administer the chemotherapy and briefed her thoroughly regarding the dosage, even providing a copy of the prescription. She and I had worked together for several years and I trusted her. She gladly offered to administer the medication.
Unfortunately, an emergent cardiac surgery case occurred on the same weekend and the anaesthesiologist, being ‘pump-qualified’, had to take responsibility for that case. She briefed a substitute anaesthesiologist and felt that the situation was well in hand. However, the pharmacist made a decimal point error and instead of preparing a dose of 97 micrograms of Actinomycin-D, he sent up a syringe containing 970 micrograms. The substitute anaesthesiologist did not recognise the error. This massive overdose was administered intraoperatively.
It was not until several hours later that the error was identified. While I was making evening rounds, I saw the syringe that had contained the Actinomycin-D, still attached to A’s medical record (a standard procedure at that time), and the label revealed the dosage error. I was shocked! Although not immediately toxic, the effect on this child’s bone marrow would be profound, beginning about a week after administration. I was reasonably certain that this child was going to die – and I was ultimately responsible!
I called my consultant immediately and, after calming me down, he said some things that really resonated. “Dan, we do not know that A is going to die. We can expect that she will encounter severe bone marrow suppression and gastrointestinal toxicity, but we do not know the outcome of that, and we need to be factual when we talk with the family.”
The following morning we met with A’s parents. My consultant wanted to take the lead in the conversation but I insisted that as A was my patient I wanted, and needed, to do the talking. I was the one who had originally met with the family and this was my responsibility, not his. I carefully explained to the parents that A had received a higher than desired dose of medication and that we were very concerned about this. I apologised for this error and explained that we would investigate this further in order to ascertain how it had happened.
I promised to correct any discrepancies in care identified in order to prevent this from ever happening again and then outlined the steps we would take to protect A. I promised the parents that the comprehensive resources of our institution would be mobilised to support A. I did not tell them that I thought she would die because her death was not a certainty, and voicing my concerns would have served little purpose.