Wednesday, December 03, 2008

Lessons from (Open) School

The Institute for Healthcare Improvement has a wonderful adjunct to their in-service training courses, a section on their website called "IHI Open School." Here, people participate in discussion threads about interesting cases in hospital management. One of the threads is, "The wrong-site surgery at Beth Israel Deaconess Medical Center," based on how we handled our "never" event back in July.

I have enjoyed reading the back-and-forth on this website. Recently, there was comment that was so honest and revealing that I made note of it, and I want to share it with you here:

While this was an unfortunate incident that resulted in a life changing outcome for the patient, it did provide an opportunity for Beth Israel to improve on their time out process. As a nurse, I can relate to the guilt that the surgeon felt when he realized his mistake.

During my early career as a nurse I administered the "right" medications to the "wrong" patient. I retrieved the medications from the pyxis and cross referenced them against the patient's medication administration record. I then left the MAR in the nurses station and went into the patient's room. I called the patient by the name of the patient's medication that I had retrieved from the pyxis. He replied to me and did not dispute the fact that I called him by the wrong name. After I administered the meds and walked out of the room I immediately knew that I'd made a mistake. While it was difficult to call the doctor and admit to my mistake I felt better about the situation because I was not punished and given a verbal lashing. Instead the doctor reassured me that everyone makes mistakes. He told me the signs and symptoms to monitor for and then gave me call orders in the event of complications.


Admitting that you've made a mistake requires alot of courage. Denying and defending your mistakes, however, is a dangerous approach. Especially as it relates to a patient's life. As a result of my error and my admission of the error our hospital designed a better process for identifying and verifying patient identity prior to medication administration. If these mistakes had not been made, reported, and then investigated, we would have continued operating by a flawed system that we "thought" was efficient.

2 comments:

Anonymous said...

Confession is good for the soul, and we all have such mistakes burned into us. However, this nurse's experience illustrates another important point, especially for those who believe the "consumer" should be in charge of all these identification issues - many patients are elderly, scared to death, afraid to contradict "authority", too sick to pay attention, or a myriad of other reasons why they would respond to the wrong name like this patient did. That's why I will stubbornly continue to call them *patients* instead of *consumers*. I do not believe health care is a commodity to be sold, but a sacred trust of which to be stewards. Unfortunately, this attitude is sadly diminished these days.

Eva said...

Hi Paul,

Great to see the IHI Open School for Health Professions featured on your blog!

Since having met you when you guest lectured in Dr. Berwick's class earlier this year, I have become part of the IHI team. As part of my work at the IHI, I've taken a note from your wonderful blog and help contribute to the IHI Open School Blog. The IHI Open School Blog is just another outlet for students to discuss anything and everything related to health care, quality improvement, patient safety, etc. Please stop by whenever you have a free moment in your busy schedule!