The national health service in the UK was one of the first healthcare systems in the

world to give priority to patient safety. The work done in the UK over the last few
years has involved taking account of the things that go wrong in health-care. The
frequency of medical error and unsafe is much higher than we have realised in the
past something like 1 in every 10 patients admitted to hospital suffer from some
form of medical error it may not always lead to serious harm but in some cases
sadly it leads to major disability and even death. One of the incidents we've
examined in depth is the phenomenon of intrathecal injection error this is where a
drug intended for use intravenously is given instead into the spine mistakenly the
patient then experiences paralysis and even death. When we've analysed these
incidents in depth we've spotted all sorts of errors and weaknesses in the system
which provoked unsafe care to be given by analyzing these and by learning from
them we've tried to work out the ways in which this error can be prevented in the
future there are around 50 recorded incidents around the world of intrathecal
injection error many more may not even have been recorded from the incidents
we're aware of so far we know that they often occur in similar circumstances to
different people at different times and even in different places experts call this
situation an error trap there's a common cause and probably a common solution
with this film the world alliance for the patient safety is making the experience of
the UK available worldwide we hope that by studying this scenario and discussing
it afterwards you will be able to see the many ways in which unsafe system can
provoke unsafe care. By generalizing the experience of this particular incident we
hope that you will be able to see the ways in which strengthening systems play a
role in reducing the impact of error this can help make health care even safer in the
future.
Just an ordinary day
Duncan:Morning
dr.L: Morning
X: dr. Livingstone
dr: yeah
X: telephone
dr.L: Thanks son. Excuse me Ducan.
dr.L: hello?
O: dr. Livingstone?
dr.L: iya
R: it's Ramesh Shah. Pharmacy here. Its about Mrs. Jane Hughes. I have rechieved
a prescription for Methotrexate that you sent down. You've already got her down
for the IV this morning, and i have sent her vincristine up. I was wondering if
there could be a mistake?
dr. L: Ah, I'm sorry. I meant to talk to you about that. Mrs. Hughes is having both
her procedures on the same day. She has a big work commitment in a couple of
days time that she cannot get out of.
R: yes, but
dr. L: I have discuussed it with Dr Munroe and he has agreed that the treatment
should go ahead. He signed the prescription.
R: yes i see. But look Fiona, this is very irregular. I assume that you will be taking
full responsibility?
dr.L: yes
R: ok then, i will prepare it for this afternoon.
dr.L: thanks Ramesh
dr.L: sorry about that. Sister Lynch; i'd like you to meet Dr Cambell. Who's just
joined us and will be working with me over the next couple of weeks. I have to
say, Duncan. That you will be giving us some much needed support
Duncan: It's good to hear. Hello sister
Anne: please to meet you. Welcome to the unit.
dr. L: By the way, Anne. Mrs. Hughes will already e on your list this morning for
the IV but she is also having her intrathecal this afternoon. She has a big meeting
at work in a few days time, so were going to try to fit her in for both procedures
today.
Anne: I did'nt know she had gone back to work
dr. L: She only just started. She is taking it easy, only a couple of days to begin
with.
Anne: allright
dr. L: So Duncan, your papers and ETN number should be through in a few days.
Meanwhile, welcome aboard.
Duncan: Thanks verry much. Ah, that is my bleep. I will take it through here, see
you both later.
dr.L: okey
Anna: dr. Livingstone before you go. I just wanted to clarify the amount of
clinical work Dr Campbell will actually be doing?
dr. L: how much have we got. He will take on virtually anything i would. If he is
unsure about anything, then i am always here to help.
Anna: so he is familiar with the IT rules?
dr. L: Well, i would certainly expect so. He is very senior Anna. He can do just
about anything i can.
Anna: but fiona, he is not on the IT register yet is he?
dr. L: No, but i am seeing Dr Munroe about that later, and we will sort it out then.
Oh, simon, I wanted a word.
Anna: so hi is fine with any of our procedures?
dr. L: well, he is here on the personal recommendation of Dr Munroe, sister. So as
far as i'm concerned if the Dr Munroe thinks he is competent then i'm prepared to
go along with that. Now he will be acting as the specialist registrar and i am
hoping that you and your staff will give him every assistance.
Anne: of course we will. But Jane Hughes intrathecal will she be under your care
wont it?
dr.L: yes, i will be there
June Hughes: Hi Abby, Jane Hughes here. I'm going to be late.I am stuck in the
most awful traffic.
Abby: sister, Jane Hughes just phoned. Apparently there has been a really nasty
acvident on the motorway, and she's caught in the tailback. She says is going to be
quite late, at least two hours.
Anna: what a day to be late. Look abby. I will be off shift by the time she gets
here. I have to leave a bit early for a dentist appointment. I will put everything in
the notes, but i am going to miss the handover. So can you make sure that sister
Roberts knows what is happening?.
Abby: of course. I will get the notes ready for her.
June Hughes: alright darling, you ok? Good boy. You're being a really good boy
we'll be there soon.
dr. L: i will be there as soon as i possibly can. Do try to calm down. It should only
take me half an hour at the most. I will see you as soon as possible.
C: is everything ok?
dr. L: not really sister no. Actually that was my mother on the phone. My father
has had a coronary and I've got to get over to the General.
C: oh, I am so sorry, Yes, obviously you must go.
dr. L: Thank You, look Dr Campbell will over for me. Could you show him
around and take him through the notes?
C: yeah, I mean I have not had a chance to see the notes yet myself but I'll do that
I can. I'm sure I will manage, go on, just be with your father. I hope he's ok.
dr. L: Thanks, I will call in later.
dr. L: Duncan, can you cover for me this afternoon
Duncan: sure
dr. L: I'm sorry about the late notice. It's my father. He's had an MI and I want to
be with him.
Duncan: of course, I'm so sorry. It's no problem
dr. L: Thank You. I have asked sister roberts to go over a few things with you, I'm
sure between you, you will manage fine.
Duncan: sure, good luck.
dr. L: thank you
dr. L: Simon, it's Fiona Livingstone. I'm sorry about the short notice. My father
has had a coronary and i have to get over to the General.
Simon: I'm sorry to hear that.. ok
Duncan: Excuse me. I am Dr Campbell covering for dr. Livingstone today.
Abby: oh hello dr campbell
Duncan: Have you seen sister anywhere?
Abby: sister roberts? Yeah there she is, by the nurses station.
Duncan: thanks
Duncan: Sister Roberts, I'm Dr Campbell covering for dr Livingstone today. I
understand that she's arranged for an SHO to give us a hand this afternoon. Dr
simon Robinsom. Is he here yet?
Roberts: no, not yet. Abby, has Mrs Hughes arrived yet pleased?
Abby: No, she just called in, she's about 10 minutes away
Duncan: she is one of mine. I better get down to pharmacy for the cemo. Thanks
very much. See you later.
Roberts: okey.
Roberts: when Mrs. Hughes artives, can we make sure Bay 8 is ready for her
please?
Abby: yes, of course i will
Roberts: thank you
Duncan: Hi, I have just come over from St Stephens unit. I'm covering for dr.
Livingstone. I've come to pick up the chemotheraphy for Mrs. Jane Hughes
intrathecal metrotrexate shi is under dr. Munroe
Charlotte Green: ok. I don't think we have met have we Dr Campbell? I am
Charlotte Green. You'll be performing the procedure today?
Duncan: yeah I will be
Charlotte: right. I will just check the register just procedure. I don't seem to have
you down?
Duncan: well it should have been sorted out with dr Munroe by now. I think that
Dr Livingstone spoke with Mr. Shah earlier on
Charlotte: ok then. Sorry about this. Take a seat. Let's have a look on the database.
Duncan: It's Campbell. Duncan Campbell. It should be there, there is no question.
I'm sorry. I'm just a bit pushed for time that's all
Charlotte: oh yes, there you are. Sorry about this. Hello pharmacy?. Yes that's
right. And what is the patient name again? Sure, that's fine. It'll be ready bt 4 this
afternoon ok?. Great, bye. It seems he has only just put you on the list. Now your
patient, would that be a Jane Hughes?
Duncan: yes that's right
Charlotte: Right. I'll just check this is ready for you.
Duncan: i'm definitely running late now. That's it.
Charlotte: here we are doctor. Methotrexate, 2mg and 2 ml. This is a pain... sorry
doctor, excuse for a while I take this. Hello pharmacy. Yes, but I'm afraid he's on
lunch at the moment , can I take a message? What extenxion's that? Fine, bye.
Now where were we?
Duncan: Jane Hughes, Hospital Number 3267980 date of birth 26/12/74 batch
number VX437294
Charlotte: Excellent, now if you could just sign here and in block capitals here.
Duncan: with pleasure
Jane Hughes: bye bye sweety.
Abby: Hi jane. You must have had a nightmare journey
Jane Hughes: hi, I'm so sorry, I feel awful.
Abby: Don't worry. Gosh hasn't he grown!
Jane Hughes: Yeah he's into everything. Where are we today abby?
Abby: I'm not sure what's happening today, they are having a few problems, but
I'm pretty sure we're in Bay 8.
Jane Hughes: yas
Abby: yes it this one. Look can i take your bag?
Jane Hughes: OH thanks
Duncan: sister, has Mrs. Hughes artived yet?
Robbins: Yes, she's settling in now
Duncan: great. Would you check this methotrexate with me please?
Robbins: Jane Hughes. Hospital Number 3267980. Date of birth 26th December
74.
Duncan: Can I borrow your pen? I've left mine in pharmacy. There we go, thanks
a lot. Could you put this in the fridge for me? While I go and deal with this.
Thanks a lot
Simon: hello sister
Robbins: Hi simons
Simon: is Mrs Hughes there yet?
Robbins: yes, she is just checking in now, thanks for helping out. I've left her
notes on the side, and I will be with you in a minute.
Simon: No problem
Abby: so how's George?
June Hughes: He's a bit and bothered actually, he had a terrible tantrum in the car
on the way here. I don't really blame him, we were stuck bumper to bumper for
hours. It was awful. Anyway, he's settled down with his dad now. Could you pass
me my walkman abby? It's in my bag.
Abby: I'll just do your blood pressure then I'll get it for you
Simon: Hi Abby
Abby: Oh Hi Simon, we dont see you here very often
Simon: I've been on nights, I've just come off
Abby: could you get Jane's walkman out of that bag for me please?
Abby: So, what can I do for you?
Simon: dr livingstone asked me to give you a hand this afternoon it seems like
she's got her hands full. Sorry, Mrs Hughes isn't it?
Jane Hughes: yes
Simon: I'm dr Robinson. How are you feeling?
Jane Hughes: pretty awfull actually, I've been stuck in the car for hours. I'm so
sorry to hold you all up.
Simon: oh no problem
Duncan: Mrs. Hughes? I'm dr Campbell, covering for dr livingstone this
afternoon.
Jane Hughes: Hi dr Campbell. I heard about her father it's awful. Will he be
alright?
Duncan: I'm sure he is very capable hands. You must be dr Robinson. Thanks
very much for helping us out at such short notice
Simon: No worries. I am happy to help
Duncan: Now, Mrs Hughes, you understand what treatment you will be having
this afternoon
Jane Hughes: Yes i do.
Duncan: Right, lets have a look at Mrs Hughes blood results then shall we. That
all looks fine and the consent form?
Jane Hughes: yes I have
Duncan: Observations alright?
Abby: Right
Duncan: Right will you check the wirstband for me please?. Right. It's Mrs Jane
Hughes, hospital number 3267980 date of birth 26/12/74
Roberts: abby!
Abby: I've go to go dr Campbell
Duncan: if they need us I presume they will call. Let's just get on with this
Simon: I'll get for you
Duncan: Great. Look, before you do that would you just check the loval with me
and then I'll prep the skin
Simon: sure
M: I've asked dr Campbell twice today to call. Would you pass him a message
please?
N: Iya
Duncan: Now, you will feel just a bit of pressure here, there we are. Wonderful
that's great. Anything important?
Simon: I'm not sure really. I have taken a message
Duncan: There you go. Right, so who was it?
Simon: Someone from admin, they want you to give them a ring
Duncan: That's the third time today. Right I'm ready for the Chemo now. Simon,
I'm sorry, would you mind going to pick it up from the fridge?. I think we've lost
the staff nurse completely now
Simon: It certainly seems like it, I think there is a problem on the ward. I'll find
out what's happening
Duncan: Thanks verry much. Is everything alright Mrs Hudghes? It wont be much
longer now
Simon: Here we are. I'm afraid Abby's going to be a while yet. I've just seen her
rushing around.
Duncan: well we can't afford to waste any more time. You will just have to check
it with me, is that ok?
Simon: Fine. Checkk..
Robberts: Everything ok? Simon, dr campbell?
Duncan: yes everything's fine. I understand you've got a bit of a problem on the
ward?
Robberts: yes. I'm sorry the staff nurse shouldn't be too much longer
Duncan: Actually, we've nearly finished here. Tell me, has my next IT patient
arrived yet?
Robnerts: yes, he is in the waiting room, I have explained we are running late.
Can you check his blood results, they are not looking good.
Duncan: ok, thanks. Ignore it, just ignore it.
June Hughes: you will thank dr Livingstone for me won't you. It's such a help you
fitting me in like this.
Duncan: of course I will. It's not a problem
June Hughes: Thanks
Duncan: everything ok?
Simon: fine. Vincristine 2 mg in 2 ml.
Duncan: Allright. Ok, that's it. Got a plaster?. Brilliant
Abby: sorry to hold you up. You can't have finished already?
Simon: yeah. We have yeah
Abby: But I've got methotrexate. So what have you given her?. OMG!
Duncan: Can someone call dr Munroe please?
Vincristine is intended for intravenous use only. If injected intrathecally by
mistake, vincristine causes paralysis usually followe by death.
The film you have just seen provides a shocking example of now a series of errors
can lead to catastrophic harm to a patient. The first question you may like to ask
is: who was responsible for this tragic outcome?. The most obvious answer may
be dr Campbell. He mistakenly injected Vincristine into the patient's spine.
However, I want you to consider a far more critical question: Why dis dr
Campbell find himself in such a position? Sitting in front of a patient, with an
open spinal needle in their back, having been handed the incorrect and potentially
lethal drug. In reality, dr Campbell's error was the final act in a chain of events,
each of which had they been identified at the time, may well have prevented this
tragic outcome.
It is therefore important to carefully review cases such as this. As much as possible
we need to do this without blaming the individuals involved. That is not to say that
individuals should not be held accountable for their actions. However, although
apportioning blame may be emotionally satisfying. It is likely to drive problems
underground and impede an honest and far-reaching understanding of the risks. We
need to address these risks to ensure the safe care of future patients. Let’s turn to
the film and identify some of the factors that played a part in this error.
Adherence to Guidlines and Standard Operating Procedures (SOPs)
In most health0care settings worldwide, there are strict frameworks in place
regulating the use of chemotherapy drugs like Vincristine. (Dr. Douglas Noble).
These include prohibitions against storing such drugs in a fridge with other
medicines and giving them in conjunction with other therapies. In many countries
there are also regulations specifying registered chemotherapy nurse must be present
during the procedure and the treatment must be given in a special room or bay.
These types of frameworks and regulations are known as Standard Operating
Procedures or Guidelines. These Standard Operating Procedures and Guidelines
apply widely and are not specific to the use of drugs like vincristine. For example,
well known are Advanced Trauma Life Support guidlines from the American
College of Surgeons and the World Health Organization’s Pain Ladder for safe and
effective adiministration of opiate analgesia. In the film we have just seen you
should clearly note that the Standard Operating Procedures and Guidelines were not
adhered to.
Dr: Yes. It’s about Mrs Jane Hughes. I have received a prescription for
Methotrexate that you sent down. You’ve already got her down for her IV this
morning, and I have sent her Vincristin up.
The methotrexate should not have been dispensed on the same day as Vincristine.
A mix up of these two drugs could led to fatal consequences and a protocol wa in
place to prevent this. Had it been adhered to the error may have been avoided.
Dr: oke then i will prepare it for this afternoon
Factors that have led to the pharmacist breaking the protocol are many and varied.
They include the pressure of work and a hierarchical management structure which
does not encourage constructive questioning of the doctor in charge.
Dokter baju biru: I’ve come to topick up the cheotherapy for Mrs. Jane Hughes
Intrathecal Methotrexate
Dr. Campbell should not have been allowed to administer chemotherapy. I don’t
seem to have you down? He was not confirmed as having the skills to do this.
Despite this, the nurse was persuaded to allow him to practice on the ward and the
pahrmacist allowed him to pick-up the prescription. A system was in place but not
adhered to.
Pharmacist: here we are doctor, methotrexate, 2mg and 2 ml.
Sadly in many areas of health-care, when these procedures are in place their purpose
is often misunderstood and they may be treated with contempt. Lack of
organisational leadership, poor communication, high workloads, and inadequate
education and training all contribute to lack of adherence. Standard Operating
Procedures and Guidelines can be a great protection againt error. Their objective is
to make patients and practitioners as safe as possible each and every time that a
procedure or action is undertaken. Standard Operating Procedures do not destroy
clinical autonomy or decision making. Rather they provide an evidence based
agreed framework for protecting against error. Wherever possible, they standardise
the procedures in place so that everyone understands their role and what is expected
of them. Where Standard Operating Procedures and Guidelines are present they
must be adhered to. Where they are not in place, appropriate measures should be
taken to establish them. We need to make sure we have an organization wide view
of Standard Operating Procedures and Guidelines, sp these essential components of
safe care do not fall by the wayside. We need to see such procedures as the hallmark
of professionalism and good patient care, rather than as the enemy. When Standard
Operating Procedures and Guidelines are present, we need strong and visible
leadership to ensure they are adhered to. For your organization ask yourself the
following questions
COULD STANDARD OPERATING PROCEDURES AND GUIDELINES BE
PUT IN PLACE TO MAKE DELIVERY OF CARE SAFER? (24:38)
ARE STANDARD OPERATING PROCEDURES AND GUIDELINES BEING
ADHERED TO, AND IF NOT, WHICH PRESSURES PREVENT THEIR
OPERATION?
IS THERE A CULTURE OF CONTEMPT FOR STANDARD OPERATING
PROCEDURES AND GUIDELINES IN YOUR ORGANIZATION?
Ensuring Valid and Up-to-Date Training
Dr Eugenia Lee : We can only really be sure that we are delivering safe care for
patients if all the health-care workers involved have received the right training and
are up-to-date. A health-care professional who has not received the appopriate
training or guidance may feel under a lot of pressure to just do the job. There can
be a lot of pressure to cope with the workload by operating outside their
competence, especially for junior staff. Such staff may not be well placed to judge
their own level of competence they may be over- or under confident because o their
limited experience. This is a potentially dangerous situation where errors can easily
occur. In the film it was obvius that nobody had a clear understanding of the level
of training or experience that the newly dr. Campbell had.
Dr. Anne: dr livingstone before you go. I just wanted to clarify the amount of
clinical work dr. Campbell will actually be doing?
Dr livingstone: how much we got? He will take on virtually anything I would. If he
is unsure about anything, then I am always here to help.
Dr. Anne: so he is familiar with the IT rules?
Dr. Livingstone: well, i would certainly expect so. He is very senior Anne; he can
do just about anything I can.
Dr. Anne: but Fiona, he is not on the IT register yet is he?
Dr. LS: No, but I am seeing dr. Munroe about that later, and we will sort it out then.
(Dr Eugenia Lee) sister Lynch in fact queried this several times with his colleague,
dr LS. Despite this lack of clarity, dr campbell was left in charge once dr LS left the
ward.
(Dr. Cambell) sister roberts, I’m dr campbell covering for dr LS today.
(dr. Eugenia Lee) a culture where health-care workers help each other, especially
when staff are stretched, may inadvertently increase the risks to patients. Often,
many staff may not easily recognise the boundaries of their own expertise and
experience. Poorly trained health-care workers can be a major contributing factor
leading to adverse events. Many countries are good at ensuring a certain standard
as part of undergraduate training. However, in many cases, the last assesment a
health-care professional faces is at their University or College. Assesment are not
just about ensuring a certain and sustainable level of skill, knowledge or
competence, they are also a reflection of a wider culture of safe and effective
practise. Education and training are critical components in the quest to improve
patient safety. At the very least, all health-care workers must understand the key
concepts of patient safety. For those already in practise, programmes must be
developed to give them the skills to continue to practise safely. Most of all, helath-
care professionals should know and understand safety procedures in their own local
service context. In other high risk industries careful attention is paid to ensuring the
ongoing competence of frontline staff. For example, a typical airline pilot will
probably have something like 100 assessments of their competency over the course
of their career. In some countries, doctor have none. For your organization ask
yourself the following questions “how do you know that the colleagues you work
with have received the training they need to do their job well? Do you have a way
of assessing the colleagues you work with to ensure they are competent? Do you
have a framework in place to ensure induction with local procedures? Do you know
what you should do if you have concerns about the competence of your colleagues
and the safety of their practise? Would you be supported in raising your concerns?
How would you know if your health-care system allowed an unskilled/untrained
health-care worker to practise?
COMMUNICATION AND EFFECTIVE TEAM WORKING BETWEEN
HEALTH-CARE WORKERS
Clear communication and effective team working between different health-care
workers from different professional groups is essential for delivering safe care for
patients. In many countries, health-care is becoming more and more specialised and
clear communication within the multidisciplinary team is vital to ensure there is
clarify on divison of responsibility and roles, procedures, and outcomes. Time and
time again research has shown that ineffective communication and poor team
working has been a major cause of an adverse event and heightens risk to patients.
(dr campbell) it’s campbell, Duncan Campbell. It should be there, there is no
question. I’m sorry, I’m just a bit pushed for time that’s all. I’m definitelly running
late now, that’s it.
Dr campbell: Sister, has mrs. Hughers arrived yet?
Sister: yes, she’s settling in now
Dr. Cambell: great. Would you check this methotrexate with me please?
Sister: ok
Dr. Cb: can I borrow your pen? I’ve left mine in pharmacy. There we go thanks a
lot. Could you put this in the fridge for me while I go and deal with this. Thanks a
lot
S: ok
In the film it should be obvious that these two terse exchanges and communication
breakdowns contributed to the error. It is not just verbal communication that can be
at the heart of serious error. These professionals are not working effectively as part
of multi-proffessional team. They are not respecting each other’s role,
responsibility and supporting each other in delivering a common goal, the safe and
effective care of their patients. As you can see without verbal handover, the written
note had no context. In the midst of a complex stressful situation important
messages that shoul have been clearly communicated between staff were lost. The
lack of effective staff handovers and lack of clarity on individual roles gives
opportunities for misunderstandings to arise. Communication, can be aided hugely,
just by stepping aside into a quiet spot, even if only briefly. Staff need to have
mutual respect for each others role and professionlism, they need to be able to
respect and value constructive questioning and deal honestly with
misunderstandings. A hierarchical structure and a culture where junior staff are
afraid to speak up end effectively challenge or query the decision-making of senior
staff can contribute to poor team working and the resultinng poor communication.
Environmental factors such as stress caused by understaffing and overwork also
play a part. An appreciation of cultural differences is key skill for successful
communication in our multicultural world. This is particularly important in health-
care where health-care workers and patients may be from different cultural or socio-
economic backgorunds, making some of the sensitive aspects of health difficult to
address. Differences in language, customs and conversations and religion all have
the potential to lead poor communication and misunderstandings. Some
organizations still have a culture where respectful dialogue and enquiry is not
encouraged. We need to move away from this, to a culture which requires open and
honest communication between all players in the health-care setting. Handover and
clear documentation need to be actively encouraged and promoted. Effective
teamwork needs to be encouraged. For your organization ask yourself the following
questions
TO WHAT EXTENT IN YOUR HEALTH-CARE SETTING HAVE YOU
ADDRESSED THE NEED TO HAVE EFFECTIVE MULTIDISCIPLINARY
COMMUNICATION?
DO STAFF VALUE, OR EVEN KNOW ABOUT, EACH OTHER’S ROLES?
CAN JUNIOR STAFF APPROACH SENIOR STAFF AND MAKE A
LEGITIMATE ENQUIRY ABOUT THE SAFETY OF A SITUATION?
DO YOU WORK WELL AS A TEAM?
CORRECT DRUG LABELLING AND ACCURATE MEDICAL RECORDS
(dr James Ip) correct labelling, storage, and dispensing of medicines is vital to
protect the patient against potentially lethal harm. Medication errors in some studies
have accounted for u 30% of medical errors. Safety of medication delivery is one
of the most pressing issues of the patient safety agenda. In the film, almost
everything that could have gone wrong with Jane’s medication delivery did go
wrong. This started long before she was administered the wrong drug. Standard
Operating Procedures and Guidelines to prevent vincristine being stored with
methotrexate should have been adhered too.
Dr campbell: ah, you must be doctor robinson. Dr robinson and dr campbell had
never met before. They did not have specific training to be checking these drugs. It
should have been the certifief nurse that was involved at this level. Traditionally
health-care workers have worrief mainly about issues of adverse drug reactions,
where the patient has given the right drug but suffers from a side effect. The area
which concerns itself with ensuring the right Standard Operating Procedures and
Guidelines are being followed and the right dispensing and delivery systems are
being used, is known as medication safety practise. This is an important area which
examines health-care systems to try to prevent errors such as that in the film. We
all know how bad a doctor’s handwriting can be! Yet sometimes the medical notes
are the only way healthcare professionals have to communicate with each other.
Therefore medical records need to be clear and unambiguous. They need to provide
an accurate way of conveying important actionable information. It is essential that
all hospitals, clinics and treatment centres have established policies for ensuring
medication safety. In general, whether we are dealing with vincristine or not, there
are certain principles that you may want to consider. For example, all drugs must
be clearly labeled and labels must be easily visible. Drugs must be properly checked
by the designated person against the patient’s medical records and drug chart. And
high-risk treatments like chemotherapy drugs must only be given by nurses and
doctors with specialized registered training. For your organization ask yourself the
following questions
ARE MEDICAL NOTES EASILY ACCESSIBLE, KEPT REGULARLY UP TO
DATE AND EASILY LEGIBLE?
DO YOUR PROCUREMENT POLICIES ENSURE CONCISTENCY OF DRUG
PURCHASING AND CHECKING MECHANISMS TO DETECT POTENTIAL
ERRORS SUCH AS LOOK-ALIKE SOUND-ALIKE MEDICATIONS?
DO YOU HAVE SYSTEMS IN PLACE TO ENSURE ONLY THOSE
PROPERLY TRAINED ARE ABLE TO BE INVOLVED IN DELIVERY OF
HIGH RISK DRUGS?
THE PATIENT’S INVOLVEMENT AND PERSPECTIVE
(dr claire stebbing) of all partis in a health-care setting, patients often have the least
imput into their care. Yet, much research indicates that patients cannot only enhance
the quality of their care, but can prevent errors. When arriving at the hospital Jane
was stressed because of a long car journey through gridlocked traffic and probably
also because of the trauma of living with cancer and facing more unpleasant
procedures. Nevertheless, she was put at ease by the nurse who asked her how she
was feeling and enquired about her family. So far so good. However once jane had
been escorted to the treatment bay, she was no longer treated as an indiviual. The
multidisciplinary team failed to acknowledge her as someone who could provide
valuable input into her own care. She was not even asked what she had come for.
Could she have had a card by which her treatment was checked with her as well?
Would that have provided an additional safety barrier? Jane might have been able
to spot that the team was proceeding with the intratechal drug injection before she
had been given her intravenous treatment. Had she been able to point that out, what
followed might not have happened. It was the hospital’s responsibility to ensure
that Jane’s care was safe, but involving Jane actively in her care my have prevented
the terrible outcome. A patient who is familiar with the procedure is a vital resource
for any health care worker to draw on. They may be able to spot discrepancies in
the treatment plan and deviations from Standard Operating Procedures,
discrepancies in communication or odd drug labelling. Patient’s are often far more
insightful than we give them credit. Adopting a more patient-centred approach,
trying to look at the situation from the patient’s point of view, will make patients
feel more relaxed, more comfortable and lead to a more effective consultation and
diagnosis. It enhances quality and promotes safety. It may also save time and
money. For your organization ask yourself the following questions:
WHAT HAPPENS IN YOUR ORGANIZATION TO ENSURE THAT
ORGANIZATION TO ENSURE THAT PATIENTS ARE ACTIVE PARTNERS
IN THEIR OWN TREATMENT?
HOW COULD YOUR ORGANIZATION PLAY A MORE ACTIVE ROLE IN
THIS CHALLENGE?
COULD OTHER MEANS OF ENGAGING PATIENTS BE USED SUCH AS
POSTERS, LEAFLETS AND PATIENT TREATMENT CARDS?
The World Alliance for Patient Safety believes that we need to understand the
nature of these contributing factors. We must learn from the errors and harm we
unintentionally to patients, in order to reduce risks to future patients. We need to
act on this learning and make improvements throughout our health-care systems.
Commitment from governments, hospital management and clinical leaders is vital
to achieve this. We must also work collaboratively with patients. But let me finish
with five challenges:
DO YOU HAVE STANDARD OPERATING PROCEDURES AND
GUIDELINES IN YOUR WORKPLACE?
ARE THEY ADHERED TO?
IF NOT, WHY NOT?
COULD YOU DEVELOP THEM?
DO YOU HAVE A FRAMEWORK IN PLACE TO ENSURE HEALTH-CARE
WORKERS ARE UP TO DATE WITH TRAINING AND SAFE TO PRACTISE?
DO YOU COMMUNICATE EFFECTIVELY WITH YOUR COLLEAGUES AS
PART OF A MULTIDISCIPLINARY TEAM?
IS INFORMATION ABOUT THE SAFE USE OF DRUGS ACCESSIBLE TO
YOU?
HAVE YOU ENGAGED PATIENTS IN THEIR CARE?
Analyzing and understanding errors like this will take us away froma blame culture
and move us to situation where we can offer safe high quality and sustainable care
to our patients, not just now but in the future.