What makes an error?

I’ve been following the tweets from all the events this week, and there have been quite a few! Working in paediatrics, #RCPCH15 has been my main interest, but there’ve also been a few other streams on patient safety.  One of the themes that has come up has been around medication errors.  Some errors are clearly defined: an illegible signature or drug name; a dose calculation that’s gone wrong.  Others aren’t that simple.

Some arise from uncertainty in the medical world: there are different ways of prescribing common medicines like antibiotics, or even paracetamol.  Some medications may be more accurately dosed based on a child’s age; and others may depend on their weight.  There’s also balance to be struck between accuracy and pragmatism.  Syrups of antibiotics might be easier to dose by age because that usually means 5mls or 10mls doses; calculations by weight could mean measuring a dose of 3.76mls (which I’m not even sure is possible to do consistently).  If we prescribe a dose which is easy to measure and dispense but is less accurate than one calculated on weight, is that an error?  Or is deliberately prescribing an accurate but unmeasurable dose an error?

Some medications are prescribed pro re nata or PRN; to be given as needed. Defining when something is needed isn’t always that obvious, even when an indication is given on the drug chart.  Is my definition of “thick secretions” the same as somebody else’s? Perhaps.  We’re on much shakier ground when it comes to giving paracetamol for a fever (because I don’t usually, but I will if the fever is making a child miserable or unwell).

The other errors are even harder to define.  Before I even get as far as the drug chart, making the decision to prescribe a medication has potential for error.  What influences our decision to prescribe?  We gather information from different sources; missing a vital piece of information could make the difference between starting a medication and not; choosing the right dose; picking which preparation to use… Nursing staff who know much more about their patient than I do because they spend a whole shift with them; families who’ve spent their child’s whole life learning about them.

In a single day, I’ve relied on families to tell me that we’ve got the right preparation of an anti-epileptic medication (we hadn’t); that their child looked puffy and was carrying too much fluid; and that their doses had been adjusted since their last clinic appointment (letter not yet on the system).

Gathering the information is a vital part of the decision-making process: getting it wrong; making decisions without that can be disastrous.  Sometimes, we don’t have access to all the sources, but when we do, it is part of responsible prescribing to take account of that information.  (I am not saying that we prescribe on demand; but that we take account of all the information that we access to).

Is failing to take account of this information a medication error? Because I think it’s more of an issue than mis-calculating a dose.  It might not be as easy to measure, or record but that doesn’t mean it’s not important.

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Who knows?

Again, a random Twitter comment has started off a train of thought that a comment from @Adsthepoet had been germinating for a while (I think I’m blogging more because I don’t have him to discuss things with, so they either stay in my head or get blogged… or get inflicted on my partner late at night)

I’m not at #RCPCH15 but I’m following the tweets.  There’s a discussion about how engaged patients and families are on ward rounds (and I would suppose in the rest of the hospital day).  Adam knew this mattered “In a good hospital, the staff talk to me and involve me in my care” and I think (in theory) that most of us would agree with this.  I suspect that most of us believe that we do it; that the situations that Adam described were exceptional.  There isn’t much research about communication between parents-children-doctors, and to be honest, what there is doesn’t really reassure me that we’re doing what we think we are.  We think we’re involving children, but we’re much more likely to be making social chit-chat than discussing management options and making plans together. 

So, why does this happen? One response suggested that professionals don’t see children & families as a reliable source of information compared to the familiar ones, like medical notes (which are obviously 100% accurate and never contain any errors. At all. In any way.)

I question this.  First, I doubt the accuracy of medical notes over the recollection of children and families.  Sometimes the words and terminology are different (“she takes the blue puffer when her stomach goes up and down” rather than “10 puffs salbutamol PRN for respiratory distress”); sometimes people are tired/overwhelmed/frustrated and don’t have the answer for “when did the Nissen’s take place?” Although I have also been on the ward round where the consultant went through a huge stack of notes trying to find an operation date whilst ignoring the mother who had been by her child’s side ever since he was admitted and knew exactly what had happened and when.

Second, the medical notes tend to be just that: medical. To use the salbutamol example, they describe a medicalised view of the world that might not be relevant to that child and family.  “Respiratory distress” means different things to different people (whether clinically trained or not); asking a parent what they look for before they give an inhaler is going to give a more realistic indication of that child’s symptoms than sticking down a medical term.

I might know some medicine; I am not an expert in another human being or family.

The Dr bubble

I’ve mentioned this before, but as a doctor I live in a bubble. It’s a very comfortable place, and there are times when I really just want to crawl back into it.  

My Dr bubble is a lovely place because it’s safe. It’s a place where professionals know best, and always do the right thing. Our decisions are the right ones and when things go wrong it’s because of things outside our control. 

It’s a bubble where I only meet other professionals and we use special words. We complain about things that only we understand: the hours we work; the demands on the service; how terrible it is to have the canteen close at 6pm; and how busy we are. 

It’s safe and comfortable and invisible when you’re inside it. 

The first thing that punctured my bubble was Twitter & the people that I’ve met on there.  At first, I didn’t realise that my bubble even existed: it’s taken some very patient people a lot of time to get me to realise that it is there. (@betabetic mainly but many others) 

The more people I met, the more I started thinking about my reactions to things. Whenever a non-medic questions a decision that’s been made, I have to fight my automatic response to defend the Dr perspective.  I find myself writing responses to tweets, reading them to myself, and being appalled by what I’ve written; going back & thinking again; trying to get outside my bubble.

And it’s a scary place to be. I’ve read families experiences where professionals close ranks and cluster together. I suspect that we don’t even recognise that we’re doing it; that attempts to step outside that bubble are so alien that we retreat. I know that I do, because it is safe in my bubble. 

But it’s still not a great place to be; and it’s not why I became a Dr in the first place.

Ivory towers

This morning I tweeted about the new report that the BMA Medical Academic Staff Committee have been working on for a while, and is finally published. It’s called “Every doctor a scholar and a scientist” and it does pretty much what it says on the tin. I’m a member of MASC and I was involved in writing it, so I have a vested interested in this, but basically the premise is that EVERY doctor (not just those with an academic contract) should understand the basics of research and education in order to deliver the best quality care to their patients.

It took less than 20 minutes to get a response that included the phrase “ivory towers”.*
What exactly is that supposed to mean? This phrase suggesting the “wilful disconnect from real life” that clinical academics are accused of having is just one example of why ALL healthcare professionals need an understanding of teaching and research. (And I know this document is just about doctors, but that’s because it’s a BMA publication. I think everyone in the team – including the housekeeper on the admissions unit – should be involved).

I think this division between clinician and academic is artificial and it’s dangerous.

There are the obvious arguments about the implementation of research: it’s hard to understand how a clinician would implement the results of a trial or guideline safely without the skills to appraise the evidence for themselves.  If research is going to produce useful and meaningful results, then it needs to be pragmatic.  It seems only fair (in my mind) that a patient who is involved in a research study should have confidence that their entire clinical team has an understanding of research, and how that is regulated and carried out.  Safe & good quality care mean understanding research; and taking responsibility for training and educating ourselves and those around us.

But there is another problem with this idea that “pure clinicians” are somehow more connected with “real life” than those of us involved in research.  It suggests that clinicians don’t have an ivory tower; that, as a Dr, that I somehow understand what real life is like for the patients and their families that I see in my clinical work.

If I’m learning anything from my PhD it’s that I don’t have a clue what somebody else’s life is like; being a Dr puts you in a bubble that is incredibly hard to recognise, and even harder to puncture.

Ultimately, we all live in our ivory towers to some extent.  Maybe we should just recognise that a bit more

*Here’s the thing… I would LOVE an ivory tower, but I’m a researcher and an academic. That means that I don’t get to spend my days hiding away in a lovely library, working my way through my thesis, surrounded by musty books. I occasionally have dreams about days like that; I sometimes run away and hide in the British Library so that I can “treat” myself to this fantasy.

Bounce

It’s taken me at least three weeks to write this. I can’t think of a title. I can’t think of a way of making it coherent.

Three weeks ago, an amazing and wonderful person died.  And I miss him very, very much.  And I know that hundreds of people across the world also do. And most of us never met him in person.  But the loss is still very real.

We never finished one conversation, about what we would do if we were ever guests on “I’ve never seen Star Wars” (If you’ve never heard it, it’s a Radio 4 comedy show hosted by Marcus Brigstocke, where celebrities are invited to try 5 new things.  The list ranges from watching Star Wars, to trying shellfish for the first time).  We were thinking about what we would choose, but we were having difficulties.  Me, because I’m too scared to try a lot of things (I am NOT jumping out of a plane); Adam, I suspect, because he’d already done a lot more than I had in his 15 years.

Adam was just an amazing influence on policy-makers and NHS leaders.  A few days ago I sat and heard tributes from big-wigs and Twitterati.  I’m a junior registrar for goodness sake; what am I going to add to that? Other than I miss him.

And I have to be honest, there are some things that I don’t think that I’ll ever learn or appreciate.  I don’t like Eggheads (more of  a University Challenge fan I’m afraid, although I did try!); I might have some slight tolerance for football (but definitely not Chelsea); and I am confident that I will never understand the point or attraction of Formula 1.

The one thing that I really wanted to learn from Adam, and he was so good at sharing, was his outlook on life.  I miss his “bounce”-  I wonder if this is what people mean by “resilience”.  Because he seemed to come at things from the positive, but wasn’t scared to tell it as it was; to challenge whilst encouraging.  It wasn’t confined to areas of policy or practice (although he questioned that frequently; things that I’d taken for granted), but he extended that to me, as just me.  So when I came home after a night shift and I started questioning my every decision, Adam would reassure me.  It wasn’t trite and meaningless; it was full of sensible suggestions for the future.

Above all, he told me that it didn’t matter if I got something wrong; what mattered was that I learnt from it; that I got up the next day and went back into work to try again.

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I like to think that Adam is swimming and diving in deep green waters.  Whatever he’s doing, I know that there’ll be plenty of bounce.

Misreading the signs

Yesterday afternoon, I accidentally “high-fived” a parent in the corridor.

The part of my brain that isn’t sinking with embarrassment is screaming at me “how??  How can you possibly do something like that by accident?”

What actually happened? Walking towards each other in a corridor; family very happy to be leaving; me very pleased that they were happy… The hand went up, I went past, my hand went up, HIGH-FIVE (there was no shouting by the way).

Context: I’m a paediatric registrar.  Some things are appropriate in that context that I wouldn’t have dreamed of doing when I was working in adult medicine.  Sticking my tongue out on a ward round is perfectly acceptable behaviour, as is playing hide-and-seek during a neurological assessment.  Making the shift to a “high-five” really isn’t that unusual a move.

Re-assessment: As I went past, I saw the look on the parent’s face. Surprise and amusement.  And my brain suddenly said whoooooops

It’s a trivial incident. If they remember next time we meet, I’ll apologise; we’ll laugh about it.

But it got me thinking about how easy it is to misread the signs; how often communication comes down to interpreting subtle movements & gestures; and how easy it is for us to get wrong.

But it’s also reminded me of the checks that can be there when it does go wrong.  Some people will show this in their facial expression (but others won’t); sometimes we’ll have built a relationship over time (but sometimes there isn’t that privilege of getting to know people – even a litre bit).

So, I hope I’m forgiven for my inadvertent lapse into 1980s greetings; but I also hope that next time I misread the signs that I can get some clues that I’ve got it wrong; that I apologise; and that my future lapses are also forgiven.