I had "one of those days" the other day. Almost everything I did seemed to be wrong in some way, and I made a catalogue of (thankfully mostly minor) Mistakes. Now doctors aren't supposed to make Mistakes, we're invincible. And when we do make Mistakes we're not supposed to talk about them because we're just that egotistical. There have been various headlines in the recent press about the instant dismissal of whistleblowers (the people who have seen something wrong and tried to put it right in an effort to improve patient care, affronted a few people's egos and been booted out the door). The airline industry had similar problems a good many years ago and have since invested in Crew Resource Management Training to break down the barriers of hierarchy and allow more junior staff to speak up if they see a problem. Mistakes are considered learning opportunities in a culture that lacks blame. The only part of medicine that has a similar attitude to patient safety is anaesthetics.
So I will tell you about my day, and my Mistakes, because maybe somebody else will get to learn from them, and patient care will ultimately be improved.
The day began with the most ferocious of medical registrars (who also happened to be post nights) striding onto the ward and barking at me that I was on call and therefore should have been at handover while brandishing the on-call bleep at me. I genuinely hadnt realised I was on call, so naturally hadnt turned up. I apologised and willingly took the bleep, hoping that this wouldnt set the tone for my day.
A few hours later, my consultant came to find me, carrying possibly the first TTO (To Take Out - a discharge summary with the patient's discharge medications and further instructions for the GP for continuing care) I had ever written, back when I had no idea what a TTO really was and what meds the patients needed. He gently pointed out that I had failed to write down that the GP needed to start Clopidogrel 75mg after 2 weeks of 300mg Aspirin, which meant that this post stroke patient had had no antiplatelet medication for about 3 weeks. Had this patient had another stroke in this time it could have been my fault. Thankfully they hadn't, but I felt really bad at having made a potentially serious Mistake. The TTOs are screened by a pharmacist before the patient is discharged, so it should have been picked up by pharmacy (note it usually takes more than one mistake to lead to an adverse incident - google Swiss Cheese Model of System Failure). I was glad my consultant had pointed this out (although by now I'd been doing TTOs correctly for quite some time) but what did make me somewhat miffed was our slightly pushy pharmacist (she's the type of person who enjoys bossing others around) butting in, immediately defending herself that it wasn't her that checked this TTO, and turning round to me and in front of my consultant saying "Oh yes, well you remember we had that talk about prescribing medications after discharge." This made it sound as if I had a problem with my prescribing and made me look pretty crap in front of my consultant. In actual fact we had had no such conversation, but she had yelled at me a couple of weeks ago for accidentally signing off an electronic discharge summary before she had seen it. I thanked my consultant, assured him it wouldnt happen again, and left.
Next, I was accosted by the end of life team nurse while ward rounding with another consultant. She wanted to know if I had spoken to a patient's family about deciding whether or not to palliate her. Now, generally I would expect this to be a consultant led conversation, given that end of life decisions are consultant decisions and out of respect for the patient and their family. The nurse had assumed that because I had documented "Discuss with family regards palliation" on behalf of the consultant on yesterday's ward round that I had made the decision and therefore I should have done it. The plan had not been handed over to the afternoon consultant by the morning consultant so neither of them had spoken to the family, and I ended up looking bad again. I probably should have made sure the afternoon consultant was aware of the plan, but things are easily missed when we're all so busy with other jobs.
So I spent the day feeling rather incompetent, but at least it's given me a lot of things to write in the "reflective practise" section of my e-portfolio! I'm well aware that if these are the worst Mistakes I ever make, I will actually be doing rather well.
No comments:
Post a Comment