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.

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.

James Reason on BBC Radio 4 20.02.2012

Prof James Reason's swiss cheese model (from BMJ 2000; 320: 768-70)

Jane and I got very excited yesterday when we heard that Prof James Reason was talking on Radio 4 on Monday night about medical errors. Prof Reason is most famous for his swiss cheese model (above), and when anyone talks about human factors research, or safety in organisations, his swiss cheese model is the first thing that springs to mind. He is that good and that famous!

The radio programme called Dr – Tell Me the Truth is a two-part programme hosted by James Reason about medical errors. What I really enjoyed about yesterdays episode (the next one is on Monday 27th February 2012) was hearing from a range of stakeholders in medical errors. During the programme we heard from patients, researchers, clinicians and lawyers all relating their experiences of when errors had been brushed under the carpet and when clinicians had been open and up front that they had made an error. There was even an excerpt from a qualitative interview of a patient who had experienced a medical error in her cancer treatment and subsequently enrolled in a research project with the University of Michigan. In this excerpt you heard the patient say that she had the opportunity to talk to the clinicians that made the mistake and tell them how she was so cross at herself for not speaking out more in her consultations and not pushing until she got the response she needed. One of the clinicians there turned to her and said it wasn’t her fault (which obviously it wasn’t). The patient said when recalling this meeting that this simple experience made her feel listened to and not ignored and not like this error which was to have a huge impact on her life and health was not being swept under the carpet and ignored. This same theme was echoed again and again, where patients reported just being told that an error had been made, and being able to talk to the Doctor about it helped so much. The University Of Michigan had also been involved in lots of initiatives to create hospitals where doctors were completely open about errors. At first everyone was worried this would lead to more litigation, especially in cases where patients did not experience any ill effects of the error and did not know it had happened. However, what they found was the opposite that it actually dramatically reduced how much they were paying out in compensation for medical errors see here.

Next week they will be hearing from Sir Liam Donaldson about whether the same principles could work for the NHS. Also from other healthcare professionals. I am hoping we hear from a pharmacist too in the next programme. There are so many professional groups in the NHS that it would be a shame (and biased) if they just talked about errors made by doctors.

RPS Responsible Pharmacist Symposium 26/01/2012

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Jane and I were invited to the Royal Pharmaceutical Society (RPS) in London to attend a symposium about the responsible pharmacist regulations. It was organised by Martin Astbury (President of the RPS) and his colleagues and chaired by Catherine Duggan, Director of Professional Development and Support at the RPS. Both Jane and I were very excited to be invited and the day was even more interesting than the programme had promised. Originally billed as a discussion of the responsible pharmacist regulations it quickly led into discussions about the idea of developing a just culture in pharmacy.

In proposing this idea Martin Astbury and Catherine Duggan are breaking new ground in pharmacy practice as discussions in the literature have focused on a more general definition of safety culture. They also invited representatives from other industries e.g. Sean Parker from the Civil Aviation Authority to talk about how the just culture works in the aviation industry. Sean spoke about how the aerospace industry has been working towards a “just culture” and about their successes and failures in terms of safety management. This was very exciting for Jane and I as our mental workload research is based on research from the aerospace industry and we feel that there is a lot of ideas and measures that can be applied in pharmacy practice. What a relief to know that we have been working along the correct lines the last couple of years and that the professional body as a whole is now also considering what can be learnt from this industry.

For me, as a young researcher to be able to meet so many big names in the pharmacy practice world was very exciting. I have yet to perfect my networking skills so I was also very nervous the whole day, but the other conference delegates kindly listened to my ideas and thoughts when we broke up into small groups to discuss how a just culture could work for pharmacy. There were many great view points and it was clear that each sector of pharmacy perceived different barriers to the development of this culture. The overall biggest one was how pharmacy sits within the wider health care services, and is it possible for pharmacy to develop a new culture when they are also embedded in the culture of the NHS and their respective trusts, or communities?

Overall for me, I was just thrilled to be invited to the very first discussion and meeting about this potential shift in pharmacy culture, especially as it fits so nicely with our research. There will be a lot more work and discussion within the profession before anything is decided or done, so I will keep updating this page with news and information as I get it.

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