I spent some time in a major NHS Trust the other week, delivering two days of training at a large hospital.
The training involved very senior management, and I took the opportunity to mention the recurring incident which involves two syringes of colourless medicines being mixed up on the scrub tray.
I asked the senior management in the room, "So how do you do it here? Do you colour code the syringes, barcode them, or add labels?"
A senior nurse in the room spoke up, explaining she put Steristrips on each syringe and writes onto these. But there's no standard hospital protocol, designed to prevent the potentially severe mix-up from happening.
Sitting in the corner was the senior manager responsible for all elective surgery in this hospital. She sat there with her mouth open, realising there was no guideline in place designed to avoid or trap an easily preventable mistake.
I had an email exchange with her the following morning, and she confirmed she had a team working on the problem straight away.
What if I hadn't delivered training at that hospital? What if she hadn't attended the course that day?
Sharing best practice and national standards are sadly sorely lacking in the medical profession.
We're aware of another hospital, where recently an anaesthetist told me she administered a child with Adrenaline, not Fentanyl. This is important because Fentanyl is an opioid, slowing the heart rate. Adrenaline speeds it up.
Following the medication mix-up, the team were questioning why the child had become tachycardic, thinking something must have been seriously wrong with him. Only on return to the anaesthetic prep-room was the mix-up noticed.
Probable cause? Working with a new ODP, who drew up the drugs in an unfamiliar way and cross-checking was secondary to social team building.
Sharing best practice is so important. It is a shame that there is rarely time for medical professionals to spend a little time down the road with their colleagues at other hospitals, learning from the way they do things.
You attend a conference, and someone will often share best practice. But they tend to talk about their own hot topic, their specialist research area. It becomes hit and miss whether you attend relevant sessions.
There are locations around the country, and indeed around the world, that have solved significant issues. But sadly all too often others don't know about it.
This reminds me of the famous Donald Rumsfeld statement, about the 'known knowns' and 'unknown unknowns'.
Working out your unknown unknowns by sharing best practice between different teams is a really valuable but arguably essential step.