Patient Safety Scenario #20: Mistakes are Everywhere
This essay is the 20th installment of the monthly Patient Safety essays, produced by the Patient Safety Subcommittee of the Ethics and Professionalism Committee. The essays are written in the spirit of the aviation industry’s concept that while the captain is the “captain of the ship”, everyone on the team needs to be on the lookout for errors and speak up when an issue needs to be discussed. Actual incidents that illustrate how errors arise and how to deal with them are presented. To read earlier essays and learn how to contribute, please click here.
David Nelson, MD Chair, Patient Safety Subcommittee
Scott Lifchez, MD Co-Chair, Ethics and Professionalism Committee
Julie Adams, MD Co-Chair, Ethics and Professionalism Committee
Mistakes are Everywhere
The pre-op holding area in the hospital has four bays and fits four patients. Initially, there was only one bedside table for all of the patients’ charts, which increased the chances that charts could be mixed up. The hand surgeon talked with the administration, and after some negotiations was able to convince them that it was safer to have a separate bedside table for each patient. When the change was first introduced, the pre-op nurse did not like having so many bedside tables blocking the aisle. The surgeon took some time with her, explaining how mistakes happen in every human endeavor, hospitals included. He described James Reason’s theory that every system that involves humans will have errors. His first principle of error management is Human error is both universal & inevitable.1 Any system designed to never have errors will fail; instead, every system needs to be designed to catch every error prior to it affecting the patient. The key concept is to have multiple layers of defense, designed to catch errors as they arise. His analogy is the Swiss cheese theory of errors.2 Each person is a slice of Swiss cheese (a layer of defense), and each hole lets an error pass through that layer of defense. If you have multiple slices of Swiss cheese, the error only gets through if all the holes line up:
Each person needs to consider that it is their personal responsibility to catch every error that arises or passes through their area.
The nurse appreciated the information and agreed that separate bedside tables would prevent mixups. Taking the time to teach your team about safety illustrates another of Reason’s principles of error management: Error management is about making good people excellent. 1
However, as Dr. Reason had predicted, Murphy’s Law could intervene anytime.
Early one morning, getting ready for the 7:30 start time, the transport techs brought down four patients. When bringing in the fourth patient, the tech noted that Bed 3, its bedside table, and the curtain/partition were in the way (see Figure 1).
He moved them out of the way, rolled the gurney in, straightened out what he had moved, drew the curtain, and left.
The hand surgeon arrived on time to find his patient in Bay 3 and interviewed the patient. The side, site, and surgery were verified, all questions were answered. He grabbed the bedside chart and filled out the paperwork. Thinking ahead to the complexities of the surgery, he left. The pre-op nurse started to check that the surgeon had completed all the paperwork in order to release the patient to the OR, and alertly noted that the surgeon had written in the wrong chart.
In “straightening things out,” the transport tech had moved Bed 3’s bedside table and its chart against the opposite wall, away from Bed 3, and in drawing the curtain closed, had put Bed 4’s chart in the bay with Bed 3. The surgeon, seeing what he expected to see, a patient with their chart alongside them, did not check the name on the chart, and wrote in it.
The nurse called the surgeon, who returned to the pre-op area, verified that he made a mistake, and congratulated the nurse for being “a good slice of Swiss cheese.” She smiled, recognizing the compliment.
Every system with humans involved will have errors. You have to design your system, not to never have errors, but to catch all of the errors that arise. Murphy’s Law is working every day to destroy whatever safety measures you institute, as in this case, where each bed had its own bedside table so that charts would never get mixed up. Everyone needs to be a slice of Swiss cheese, and the surgeon needs to teach his team how errors arise and how to catch them. Each person has to make it their personal responsibility to catch every error that passes through their area. It is hard to do this in large hospitals with ever-changing teams, but it can be done. Teach the people in your room, and volunteer to give lectures on safety to the entire OR. The staff will appreciate that you took time to teach them, that you respect them enough to invest time and energy in them as team members, and they will respond accordingly.
No matter how excellent a safety system you create, stay alert for errors! Remember, Murphy was an optimist.
1 James Reason’s 12 Principles of Error Management. http://aerossurance.com/helicopters/james-reasons-12-principles-error-management/ Accessed 2/12/20.
2 https://en.wikipedia.org/wiki/Swiss_cheese_model Accessed 2/12/20.