Never events and those pesky Human Factors
I’ve recently heard of several recent never events and thought I would share the Human Factors elements as reported to me.
In a Maternity unit a vaginal swab was left in post-delivery and the doctor was found guilty by the Root Cause Analysis because he had failed to follow standard procedures. But looking at incident in more detail it transpires that he was interrupted by 4 other urgent cases in the unit while trying to deal with this one. The dangers of interruptions and distractions are well recognised and we should all work hard to reduce and ideally eliminate them.
You could argue that this is another side-effect of short-staffing perhaps?
The next was about a junior doc who had ignored the Time Out check and had helped himself to local anaesthetic and scalpel behind the scrub nurse. Instead of the trigger finger release planned he went into the wrist as for a carpal tunnel procedure. What was stunning was that this was 18 months ago and I know of an identical error at a high performing Trust 10 miles away – this Summer. It is the responsibility of all the team to ensure correct application of the WHO checklist. Many times we hear of how use of the checks slows down the flow of the day especially in small day case units, but this is what happens if you don’t. No-one would be happy to take off in a plane where the pilots hadn’t checked everything that mattered …..!
The latest report into Barrow Maternity unit make unpleasant reading too http://www.bbc.co.uk/news/uk-england-cumbria-25322238.
‘Insufficient supervision’; ‘inadequate training’; ‘failure to monitor CTG’ etc. Bad people? Maybe but probably a failure of training. Nurses, doctors, midwives are not normally chosen from the ranks of psychopaths, but in order for us all to adopt safe procedures we need to know the rationale. The investment in training pays you back in every way – the human cost – patients, relatives etc; retention of staff due to improved morale and non-acceptance of poor behaviour; reduced cost of case reviews and CNST payments.
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