Today I gained a further insight into the workings of hierarchy and patient safety.
On the ward-round we were discussing a variety of topics;
From this, as often happens we talked about one of my recent blogs, in fact, the one about the two old men, who yesterday became one, when Len (not his real name) was discharged, then this morning, Stan (not his real name, either), left the ward for pastures new.
It was at that point, we found our way to discussing Hitler, Stalin and organisational hierarchies, when one of the team – Lyndsey (her real name), pointed-out that I had made an error in my Stalin blog – I had referred to him and his fellow evildoer as 21st Century villains, when, yes, we know, they lived in the 20th Century.
What was very interesting to me was that Lyndsey had seen the error and discussed with her husband first, whether I (me, Rod) was indeed wrong (not something that happens very often) or Lyndsey had her centuries/time-periods mixed-up.
Lyndsey wasn’t going to let-on, which would have left the mistake occult, hidden-away, never to be amended, languishing in an erroneous sector of cyberspace.
My response was first, I was delighted that anyone had read the blog and second, how happy I was that someone had read with sufficient focus as to find a mistake. Hurrah.
After detecting an error or failing, the next step is to flag it – just as in medicine or healthcare, mistakes are only mistakes if they aren’t identified and there is no learning after the event.
I have now changed the blog and corrected the century.
And, moving forwards, what should happen – well, in the only safe, secure, system of health and care that can exist today, we have to be open about getting it wrong, acknowledge that errors are opportunities to learn and, that when something goes wrong, the failure is only compounded by not sharing and working-out ways to avoid repetition.
As with the challenge of insight, you don’t necessarily have to be confrontational to ask how another person perceives the world, you can be sly, you can use circuitous methodology to establish right or wrong, ‘In which century did Stalin send all those innocent folks to Siberia?’ for example.
‘Did you mean to prescribe penicillin for Margo – I thought she said she was allergic?’ or, ‘I am worried about Al, can you come and check him over.’
Perhaps the way ahead should be, after a student passes their insight exam to medical or nursing school, to challenge them with the invention of 100 non-confrontational questions.
‘When you said ‘cut’, did you mean…?’
‘Was it the left kidney?’
‘How about you try this tablet?’
‘I can’t find the defibrillator, where did you last see it?’
‘Can you remind me how…?’
‘Where do I start?’
And so on.
Asking questions is core to safety and growth and usually, having a good time.
For my indefatigable trainee practitioner buddy Lynz.
Photo – John Shuttleworth & Vince Hill (of Pebble Mill)
4 thoughts on “You made a mistake, dare I say…”
I read most of your blogs Rob and value the reflections they elicit. 🙂 Pirashanthie
Hi Rod, I’m enjoying your writing, after reading this one, I wondered if you’d read “Black Box Thinking” by Matthew Syed? It gave me a bit of an insight into medics dealing with errors.
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Hi – thanks. I have read some of the book & saw Matthew Syed talking this year at a conference. At a conference today in Doncaster one of the speakers ended by saying how little they knew – they could be doing the right thing, or have it completely wrong. It’s that openness that is fundamental to safety in healthcare. Rod