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Posted by Ishani Ganguli September 19, 2011 08:00 AM
Ordinarily, I would have griped about the incident with my co-interns and moved on with my day: While I was on call, a patient arrived from the Emergency Department (ED) to our floor without verbal pass-off (read: phone call) from the ED. This pass-off is standard protocol meant to let us know that the patient is en route and to communicate key information - Is he in stable condition? What drugs did he receive in the ED?
So I called the ED and talked to the responsible provider, who was apologetic - she had spoken to the patient’s primary care doctor who had arranged for the admission and hadn’t realized that she should contact me as well. No harm done, I thought. Now to get on with my work.
During rounds, I mentioned the incident in passing and an attending involved in patient safety at MGH encouraged me to file a safety report. I’d heard of these from friends but had never submitted one, and I added the task to my To Do list.
This particular misstep was a “near miss” in safety parlance, which means it didn’t actually harm the patient. In the swirl of a busy internship day, such errors are easily brushed aside - why dwell on the past when the present demands so much of our attention?
The answer, of course, is that we need to understand why things go wrong in order to prevent future errors - not only the well-publicized catastrophic errors but the minor ones that, unchecked, have the potential for real harm.
Since the 1999 Institute of Medicine report that defined the modern patient safety movement, this growing discipline has embraced the idea that we should be blaming systems, not individuals, for medical errors. Consensus has since trended towards the middle of the spectrum: we need to address systems flaws while holding individuals accountable. In this case, this might mean finding a better system of identifying the contact person for a patient who is being admitted to the hospital and sending reminder emails to providers who fail to follow through.
As trainees, we are exposed to or involved in an alarming number of medical errors - in one survey of 889 medical students and residents published in 2008, 98% of residents reported some personal experience with errors. It might feel like a distraction from patient care, but it’s important to get into the habit of promoting patient safety early. This requires trainees to be scrupulous and for supervisors to encourage and role model this behavior: though I’ve spent time thinking and writing about patient safety in the abstract, I wouldn’t have thought to file the report without that attending’s suggestion.
An hour or two after rounds, I ran into the attending in the hospital lobby. He asked if I’d filed the report yet (I hadn’t) and the thought crossed my mind, would he now file one on me?
Nope, but he was going to see to it that I got mine done.
He accompanied me to a workroom and helped me fill out the online form. Soon after, I received an email thanking me for my safety report (#88388) and days later a second email, telling me that the report had been reviewed by the Center for Quality & Safety and was under investigation.
The safety report was easy enough to file—the incident had little emotional valence for me because no one was harmed and I wasn’t in the vulnerable position of admitting my own fault. And now I know what to do the next time.
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