Error Diary

On Friday I found a great website called error diary which I wanted to share on here because I really love the idea behind it. The aim of this website is to get people talking about the everyday errors that we all make so that we can start to think about errors in a new way,  instead of just beating ourselves up about them and not learning from them.  I also thought it might be of interest to those lucky people who are taking part in our research, other pharmacists and anyone interested in this area of research.

You can read all about the origins of error diary on the website, but from what I can gather it was created by some researchers at University College London – in particular, Dr Dominic Furniss. The website is supported by a grant from the EPSRC (the Engineering and Physical Sciences Research Council) – this same grant also supports a huge study called CHI+MED which is looking at human error in the context of healthcare professionals’ interactions with medical devices (e.g. medicine pumps).

I should point out here that the pharmacy world is clearly aware of the work that the CHI+MED research team are carrying out because Prof Harold Thimbleby one of the members of the CHI+MED management team was presenting at the Royal Pharmaceutical Society Medicines Safety Symposium today in London. I am hoping this means that he will have inspired lots more research into human error and pharmacy systems.

Errordiary.org also has a page dedicated to resilience strategies. Those things we do to help us avoid making the same error time and time again. I have developed quite a few resilience strategies whilst running our experiments, to stop me forgetting to do or say  something. I have a script that I read from when I am briefing our participants (in fairness this is just best practice for anyone running experimental studies with human participants). I also have a post-it note with all the things I need to remember to do when running the study that sits on my computer desktop (on one of those electronic post-its that you can get on windows 7). It is very useful especially because I often run two participants at the same time which can open up lots of opportunities for errors to occur. One thing the errordiary website has inspired me to do is start noting down (with their permission) all the resilience strategies that my participants tell me about in their debrief. All those things they do on a day-to-day basis in their dispensary to avoid making an error – I am also going to write my own down as and when I notice them occurring.

Now that I have found these great sites and the CHI+MED project, I am sure I will be writing more about their work in future posts.

Image source: errordiary.org

James Reason on BBC Radio 4 Part 2

Back in February I got very excited and wrote a post about a 2-programme BBC Radio 4 series presented by Prof James Reason. I have finally had chance to catch up with the second part of this programme – even though it aired on 5th March! Yes I have been that busy. I like being busy though so I am most definitely not complaining.  Before you read this, you may want to read my earlier post which introduces the programme.

The second installment, I am sad to report did not include pharmacists amongst the healthcare professionals invited to talk on the programme. I had hoped it might, but it is only a 30 minute programme and they really were going for the heads of the big NHS /NHS related services so, it is not surprising. Despite the lack of pharmacy input into the programme, it was still very interesting and there were lots of points that could easily apply to pharmacy practice.

Firstly Sir Liam Donaldson, Chairman of the National Patient Safety Agency commented on his own visit to the University of Michigan Health Centre who have been looking at the effects of an open policy to medical errors over the last decade (which was the focus of the previous episode of this programme). He said one thing he noticed that was very different was the training that was given to staff on how to talk to patients about the errors that had been made with their care. He also noted that the support that was provided to the patient and the family was much more than just an apology that they stayed without them throughout the whole process. In terms of our work into mental workload, the emphasis would definitely have to consider both how to train pharmacists to avoid errors, but also how to deal with them if they did happen (especially if they happened because of mental overload).

Next, a representative from the National Reporting and Learning Service talked about how the approach to errors has changed in UK healthcare over the last few years. How she felt that the daily reports (e.g. before staff started their shift on a ward) had changed to include a focus on situations or patient issues that had the potential to lead to errors being made. Again this could easily be applied to pharmacy practice (this may be especially useful for locum pharmacists).

By contrast Peter Walsh CEO of Action Against Medical accidents painted a much bleaker picture of our healthcare system today. He spoke about a case his organisation has been dealing with where the errors that had been made in a young man’s care was covered up. This young man died because of these errors, and at the time the family were made aware that some errors had been made but they were not given the full story and shockingly neither was the coroner. Peter Walsh said that cover-ups were still tolerated in our health system and that this needed to change. I agree with this, but for this to happen I think we need to implement Sir Donaldson’s observation that healthcare professionals need to be trained and supported in how to be open with patients when errors occur.

For me, it is so exciting that these programmes have been aired in the last couple of months. Pharmacy is making a huge step at the moment to changing the safety culture and for that to happen the NHS needs to be making that step too, because ultimately the pharmacy profession works within the culture of the other healthcare services and systems in the UK. The fact that this is being talked about now, gives me hope that healthcare as a whole is moving towards this change in culture…but we shall see what happens.

Student Study & Community Pharmacist Study Updates 14.03.2012

Image by Roger Hargreaves

Sorry for the lack of study updates recently, it has been a busy few weeks. It started with a weeks worth of media coverage of our community pharmacist study that we have just launched in various pharmacy publications – who would have known a project not even completed could create so much interest? For this Jane, Marjorie and I are so very grateful and very excited – we hope there is just as much interest next year when we have data to publish.

In between that I have been testing participants for the student study. We are now up to 40 students through the first experiment so we have almost hit our total for the first study (52). I am hoping we get our last few recruits soon because I cannot wait to look at our data. The database is looking so lovely and full – it’s odd, but to me it really is a thing of beauty. This is probably because I know how many hours of hard work has gone into filling the database and it’s amazing to see the slow but sure outcome of all our efforts.

With regards to the community pharmacist study, the big news is that we got ethics a couple of weeks ago and I have now sent out information about the study (as of today) to pharmacy chain CEOs and superintendent pharmacists, to ask their permission for me to do research with their organisation before I contact their local and regional pharmacy managers about it. The independent pharmacy and small pharmacy chain letters are in process too and I hope I will get them out tomorrow. So we are definitely on a roll.

In between that I have been doing a lot of demonstrating work – which is basically a teaching assistant role for university workshops. I love these sessions – even when I do the same session several times over with different groups of students. However, it does take me out of the lab for hours at a time, and/or away from my desk and so I have noticed that my research time has more than halved in the last few weeks. There are only a few more weeks left of teaching for me now until next October, so I am making the most of it because I really do enjoy working with the students.

In the odd moments of calm I have also been busy working with Jane and Marjorie and some of our other colleagues on papers and grant proposals.

How I have found time to do all this I just don’t know, in fact now I read this it is no wonder I have felt like a headless chicken the last few weeks. Ironically, my mental workload has been very high at times (mostly due to time pressure) and I have noticed myself missing things, doing things wrong or forgetting to do things. So it’s not only pharmacists that may be affected by mental workload, it may be researchers too!

So as you can see it has been an amazing few weeks, busy, but in the best of ways. I have yet to have time to listen to the second installment of the Prof James Reason medical errors BBC radio 4 programme that I wrote about here. I hope I get to listen to it by the end of the week and I will write about it then!

Brian Goldman: Doctors make mistakes. Can we talk about that?

Recently a video was uploaded to TED of a TED Talk given by Dr Brian Goldman (click here for the talk). Dr Goldman is an Emergency Room doctor in Toronto. His talk was about the consequences of doctors not being open about the errors they make. This video really complements the BBC radio 4 programme by Prof James Reason that I wrote about yesterday. The ideas covered are very similar, but Dr Goldman talks about his own errors and the experiences after it and what he wished he had done differently and how much he wished he could have spoken to someone about it.  He gave a very moving talk about the errors he had made and demonstrated just how much emotion healthcare professionals feel when they make an error and how gut wrenchingly sorry they are when it happens. Which is probably why the University of Michigan reported a reduction in compensation costs for medical errors when a hospital switched to an open reporting culture. On Prof Reason’s radio programme patients talked about the importance of being able to talk afterwards to the doctors who had made an error with their care. The University of Michigan team also commented that when doctors were open and spoke to their patients about the errors made, this meant that litigation processes were stopped, or were never even started in the first place because patients didn’t feel like something unjust had been done to them once they spoke to the doctors. My thought after watching and listening to these two programmes was, is the reduction in compensation costs for medical errors in Michigan because patients get to see doctors and therefore can see how sorry the doctors are, can see that those emotions are authentic and that they weren’t taking the error lightly? You can judge for yourselves, I now have to go off and read all these University of Michigan reports as I have to find out more!

One other thought I had after watching/listening to these programmes was that there is a lot of noise in healthcare at the moment about openness towards errors. What I am not sure about is whether this is something new, or I am only tuning in to it all at the moment because of the research I am doing, and because of talks within the pharmacy profession about creating a just culture (one aspect of a just culture is openness about errors). I clearly have to do some more reading of the literature to find out.

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