Celebrate success 2
What a great afternoon, enjoying the company of 20 Foundation doctors and their tutor.
One had experienced a Human Factors issue with wrong patient, wrong notes where she had been handed notes for a patient and what she was seeing didn't match. Correct presentation, wrong side (leg). Initial thoughts 'oh no the patient has developed the same problem on the other leg and I had previously missed it'. However this prompted a second look at notes and ID and of course they were for a different patient. Fortunate that the problem was apparent or who knows what might have developed, under conditions of doctor fatigue, time pressure etc. Small success but saved a major potential problem. Learning point - check the classic Loss of Situation Awareness Red Flags' - in this case differing information from two sources. The notes and mark one eyesight.
In the morning I had met a Medical Director who actually deals with unacceptable behaviour by his team members. He operates what is apparently a genuine Just Culture and receives emails and other contacts reporting bad behaviour, rudeness to staff and patients, non-adherence to protocols and checklists and poor hygiene.
I thought at first it was too good to be true, but it seems not. He has removed three senior consultants who would not or could not mend their ways. What prompted this exemplary behaviour by the MD seems to have been a tragic error that he made many years ago. I don't know the details and don't need to, but this is not unique as a motivation. Now he presides over a multi-site Foundation Trust which has had publicly acknowledged problems in the past but seems to be well on the way to safe practice.
We are being engaged to conduct theatre team training shortly because despite best attempts a couple of never events have recently occurred. One in particular was down to the surgeon leaving theatre before completion of Sign Out. The swab count was incorrect and a small swab had been left in the operative area. The theatre team had tried to no avail to keep the surgeon present but he had declined and left. This is what checklists are about - checking quite literally that things are not omitted or forgotten. It is not an insult to professionalism, but quite the reverse. Simply an aid to safety and fallibility.
Lesson - cross check, swallow pride and act professionally, not like a spoilt child.