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
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.
Analyzes 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 that might lead to errors and call attention to it in a commanding manner.
They need training to break down the issue, assess and then make strong direct recommendations that lead 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 checklist 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.
It is a time to stop and think.
