Atrainability Blog

Here we share some thoughts, insights and ideas related to Human Factors Training

Honesty is the best policy?

Trending today in the news is the story of a transplant gone wrong.

The Oxford University NHS Foundation Trust agreed £215,000 of damage for one of the resulting cases, where a 36-year-old patient died of an aneurysm caused directly by infection from a donated liver.

Two other patients who received transplanted organs from the same donor also became ill.

The story relates to an incident in 2015, where the surgeon harvested several organs, but nicked the stomach during the retrieval process, spilling contents over the other organs, resulting in infection.

As much as we don't like to speculate, we have to question what was happening in the mind of the clinician who must have been aware they had perforated the stomach.

There is serious learning from this incident, for all involved. We must now ask how the experience can be best disseminated, in an effort for this to never happen again.

What I would hope to see from the surgeon involved is humility. One assumes they would be embarrassed and, in the spur of the moment, elected not to report the incident. Which of us hasn't made a comment or decision in a single moment, we haven't subsequently regretted?

One would hope that a professional, in whatever field, would be able to swallow their pride, overcome their embarrassment, and do the right thing, for the right reasons; the essence of professionalism.

We can't afford everyone to go through learning by trial and error. People often throw out the line, "lessons should be learned", but let's consider first what those lessons should be.

There's an opportunity for someone who has been through this experience to share their learning with colleagues, turning a severe negative into a positive.

I know from my time as a training captain in aviation that, to make a mistake as an expert, we must share that experience with others. We are held to a higher standard.

Where mistakes happen as a professional, you must swallow your pride. You must try to find a positive out of what is a devastating incident.

I can understand why the patients and their families would seek to apportion blame in an incident like this. But I would hope that the event was unintentional, and failure to admit their mistake (and be honest) at the time, a failure they have subsequently lived to regret.

What would striking off a clinician achieve? As long as they accepted their role in the mistake, that is. Assuming this is the case, they possibly become the best person to teach others.

If they demonstrate reflective learning and the appropriate attitude, and of course the duty of candour, with support from colleagues and management share what they have been through, hopefully that could produce some benefit for others in a tragic situation.

We do, however, meet people who won't accept their part in such incidents. These people are a real worry. When the attitude is, "well, it's just one of those things!", that approach isn't good enough.

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