This piece was put together by: Dr Andrew Alalade, Dr Adetunji Oremakinde & Dr Biodun Ogungbo.
They tried to make me go to rehab
But I said, “No, no, no”
Lyrics by Amy Winehouse
Medical errors occur all over the world, and not just in Nigeria. However, proactive steps have been taken to keep this to the minimum. Safeguarding measures have been instituted and regular quality control is undertaken in many countries.
A lot of corrective steps have been copied from the air industry, and replicated in the healthcare sector. When the workplace is well-structured and has seamless organisation, the staff are keen to contribute effectively towards productivity. ‘Healthy’ and ‘Safe’ people get more things done.
No matter the hospital or health centre, health and safety in the workplace benefits every employee. The aim should be to regularly make the processes easier and more straight-forward to comply with. Unfortunately, we have not developed a coherent and systematic approach to prevention, recognition and dealing with medical errors.
Prevention is better than cure
The best way to deal with complications is to make sure that they never happen in the first place, by organizing the workplace which will ensure that the important things get done while preventing unwanted things, like accidents from happening.
Human errors often lead to morbidity and mortality and so we need to understand them and mitigate such errors. Every mistake needs to be thoroughly investigated and discussed (without blaming individuals). The objective should be to learn from our mistakes or “near-misses” in order to enhance safety and improve the failures. Ultimately, this will lead to improvement in quality of care and enhance productivity in the nation.
A radical change in our thinking is required in Nigeria. There’s no point repeating old and archaic methods that have always generated the same results. We need a seismic change in attitude, behaviour, in practice and in reaction to events especially as regards medical errors in clinical settings. “We need to go to Rehab!”
The question is where we start from.
The System, stupid…..
To achieve a lot more, a systems approach is needed. Focusing on the system generates more of a ripple effect than focusing on individuals. The aviation industry has learnt so much about mitigating errors, and it is worth borrowing a leaf from their book. Traditionally, investigations into the causes of aircraft accidents often focused on what happened and who did it – but very rarely on why, which is a principal question. The industry now analyses not only on human error in flying accidents, but also on predisposing errors made by management and government.
In order words, system failures that may in turn predispose to human errors.
The system can be interrogated and analyzed in order to prevent failures. We can define what went wrong, measure the extent, analyse it, improve things and then put in systemic controls. A systematic protocol-driven approach creates a step-by-step pathway that everyone adheres strictly to. Veering off this pathway is discouraged, as they cause the system to be vulnerable to errors. This approach leads to the users learning from errors in order to prevent future errors. The consequent effect will be better education, training, change in working conditions, and in the system to prevent/reduce errors.
Single versus Multiple philosophy
Dr Kofo Jones always took blood samples over the weekends, and duly sent them to the lab. The departmental records soon discovered that the patients admitted over the weekends turned up days later with overwhelming infective illnesses. Initially, no one batted an eyelid but after monthly review meetings were organised, the ward manager found out that the sampling kits were always left out from Friday evening for the weekend doctor. Dr Jones had also not attended the new infection prevention course, so was not aware of the new guidelines set up by the microbiology department. Changes were made – the sampling kits were signed for on Saturday, Dr Jones attended the course and unsurprisingly, there were no more infections reported.
Our rehabilitation starts from understanding that an error does not occur from a single cause but rather from multiple causes. Doing a complete and exhaustive “root cause analysis” (RCA) will enable us to unravel several factors and the root causes for each. This is aided by not focusing on the sentinel events, but also analysing minor and no injury events averted through individual interventions. Patterns, habits, recurrent tendencies etc. associated with mistakes should be extensively analysed and discussed, and then amended.
It is important to recognize that the factors responsible for a major incident are the same factors responsible for near-misses and other accidents that did not lead to harm. So, understanding the causes of near accidents will ultimately lead to prevention of more serious sentinel events that are injurious.
Prevention of medical errors.
Human equipment ergonomics is important. There are situations where the names of patients, drugs or equipment are similar. Two people called Imran Khan can be admitted to hospital at the same time, and unique identifiers plus extreme care will enable us to prevent a mix-up and mishap. This also goes for drugs with similar names (Chlorpropamide and Chlorpromazine) or similar packaging (Potassium and Lignocaine).
Mistakes can be made easily if we do not pay attention to detail or find real ways to distinguish them.
Own up to errors
When errors are made, we should own up and account for them. All errors, no matter how inconsequential should be counted and reviewed. It is the little errors, omissions, commissions and near-misses that eventually lead to one single error with fatal consequences. Analysis of near misses, and the correction of such loopholes will allow us to prevent the big complications from occurring.
The concept of flat hierarchy.
This is an important concept that allows ease of communication and mutual confidence. It recognizes that sometimes a different perspective may make things a lot clearer. This concept calls for flattening of the hierarchy making it easy for subordinates to voice opinions that might prevent errors. With this, the Boss is not seen as unapproachable and out of touch. If your staff cannot talk to you freely, they will or might not share vital information. Mistakes are more likely to happen when the anaesthetists and theatre nurses are afraid of the operating surgeon – Professor Chief Okpati Yusuf.
No human being is infallible; “even the almighty Prof.” can make a mistake. If his work colleagues cannot talk honestly and openly with him, he is more likely to operate on the wrong side without being corrected.
SBAR: Situation Breakdown Assessment and Recommendation.
Free and clear communication should be taught and encouraged. If staff can talk freely, then they also need communications skills that ensure they are taken seriously. The first is to recognize situations than might lead to errors and call attention to it in a commanding manner. They need training to breakdown the issue, assess and then make strong direct recommendation that leads to action.
For example, someone can say, ‘Hey Boss, I can smell gas. A pipe may be leaking. Don’t turn on the light till we find out.’ This catches attention, breaks the situation down in a clear and understandable manner and immediately makes a reasonable recommendation.
A call to action that demands a response.
Swiss Cheese model.
The Swiss-cheese model was initially developed by James Reason to illustrate how the analysis of major accidents and catastrophes usually uncovered multiple, smaller predisposing failures that allowed a hazard to manifest as a risk. In experience with risk management and incident investigation, a serious incident requires half a dozen or more pre-conditions to all align. Some of these were pre-event and some post-event but in every case, any one of a number of barriers could have prevented the resulting incident if it had been highlighted and sorted.
In Reason’s Swiss Cheese model, each slice of cheese represents a barrier, any one of which is sufficient to prevent a hazard turning into consequences.
The Swiss-cheese theory works on the assumption that no single barrier is fool proof. They all have failings or ‘holes’ and when the holes align, a risk event can manifest as negative consequences. The model also highlighted that the healthcare professional is the last gatekeeper before the patient. If a mistake can be nullified, then it’s the healthcare professional who is likely to counter it.
For example, if a wrong prescription comes in for a patient, the person tasked with administering the medication should be able to prevent a wrong medication being given. Unfortunately, if they assume that the prescribing doctor knows best and do not flag up the mistake, the patient might get the drug and either die or get irreversible side effects from it.
However, if one member of the team identifies the error and flags it up, the patient might be potentially saved from the dire consequences.
We need to go to rehab!
To reduce complications in healthcare facilities, we all need a serious rethink. This article says we should look at the system for failings and not punish the person. The system should be set up to prevent errors. In effect, it is not about the nurse who gives the wrong blood to the patient, but the failings of the system that did prevent the error.
It also makes a case for enabling juniors to participate actively in preventing errors by being able to talk to hierarchy. We should empower the different levels of care to act as barriers to complications. This is amplified by the World Health Organisation (WHO) surgical check list for use in operating rooms. This involves engaging all members of the team and ensuring they all understand their roles and involvement in the surgical procedure. There is evidence that the WHO check list has saved lives by reducing surgical mishaps (this has been well proven in the high-income and low-income countries).
It is important to create a time out before engaging in procedures such as giving a drug, a blood transfusion, physiotherapy activity and any clinical procedure. This allows a time to avert mistakes by reviewing the processes and actions. A time to stop and think.
A time to attend rehab!