A Situational Violation
Authors: Nicola Davey (QIC) and Trevor Dale (Atrainability)
Picture yourself in this situation; you’re an Anaesthetist who has been called to attend to a patient who needs an emergency C-section.
There’s a small window to act fast and save the baby, but you notice that the patient isn’t wearing an identity wristband. Would you anaesthetise?
Before we go any further, consider this similar situation before making a decision on what your course of action would be. Again, a real-life story that we’ve been made aware of recently. A small boy and his mother are rushed into a busy A&E department at an NHS Trust, the boy having been mauled by a dog.
The child is quickly referred to the Trauma Team and there is no doubt that they have the right child; he’s covered in blood, bite marks, screaming and the mother is upset as you’d expect. They do what needs to be done, they do their jobs, clean wounds and patch him up.
Afterwards, they find out he’s got the wrong wristband on. The hospital decides to deal with this error with disciplinary action against the Clinicians.
Take a step back and you can see how a small mistake like this can occur. A busy department, a small boy screaming, arms flailing about…he requires urgent medical attention and it’s clear what he needs; but why go
Treating individuals of any specialty, nursing or clinician like responsible professionals is almost guaranteed to have a much better outcome.
This incident should have been approached as something to learn from, a discussion point. A team conversation in which this error is highlighted and shared. An opportunity for staff to explore all the circumstances which led to the name check being missed, to think about the likelihood that this could happen again, and then if necessary, think about steps that can reasonably be taken to avoid a repetition of this error.
Using a risk matrix can help differentiate between low frequency events with very serious untoward outcomes and those with much less serious outcomes. And of course, the risk of not taking action must also be assessed to give a balanced perspective.
Let’s think again about the mother who needed an emergency C-section.
On this occasion, the Anaesthetist refused to anaesthetise the patient because of the missing wristband, which lead to a ten minute delay while they got a wristband on her. The result of this, was that the precious opportunity to get the baby out safe was missed. The child is now permanently brain damaged.
The easy thing to do is blame the Anaesthetist. He or she could have acted differently, taken a risk, broken a rule to act fast and then justified his/her actions later.
Or perhaps the finger of blame points at the nurse or doctor who was responsible for making sure the patient had a wristband on?
Of course, there’s other elements to muddy the waters.
What does this individual normally do? Flout rules or routinely demonstrate good practice? Do they have previous history which led to this particular decision? Were they previously involved in, or even just exposed, to a patient misidentification that resulted in serious harm?
Patient misidentification is known to contribute to errors and is a cause of patient safety incidents; including operating on the wrong patient, or performing the wrong procedure, or performing surgery / an intervention on the wrong body part (e.g., right vs. left knee replacement operation).
So what’s the answer here?
It’s a tragic story and an upsetting, ongoing experience for all involved. We feel however that it highlights how easy it is for leaders to unintentionally get it wrong and in doing so, stopping professionals from getting it right.
One major factor in high risk decision making has to be whether your front line team feel safe and supported. Now, what that means to us is that a management system needs to be set up and run in such a way that makes front line staff feel safe. This must be borne out in reality, as opposed to being implied and then not acted on when the time comes; “Well of course you’re safe with us, we operate a no-blame culture”. Saying it doesn’t make it true.
Did the Anaesthesist feel safe?
If frontline staff feel they have to protect themselves first from disciplinary action or being struck off then that’s how hospitals end up with staff who will refuse to do something that in hindsight would have been the “sensible” action. The sense of covering one’s own back is a normal human reaction to a perceived threat and it is a clear signal that all is not well with the system.
If individuals and teams feel safe and supported it will reduce stress and they will feel enabled and empowered to make better decisions. This not only means better care and outcomes for patients, but also builds trust and team morale.
Quality Improvement Clinic are now working alongside Atrainability to offer a one-day Masterclass which combines Human Factors and QI Science. Find out more or Register for the event below.