A New Way of Thinking

A few weeks ago, I overheard one of the interns worrying about accidentally prescribing a medication and giving to patient the wrong dose frequency. The error was picked up by another resident who is on the cardiology consult service as the medication was felt by the cardiology team to be contributing to the patients presenting issue (symptomatic bradycardia).

I will admit that at the time I was only concerned with reassuring the resident that he would not lose his residency spot due to this error, as the patient was still alive. When the resident was consoled I forgot about this issue. Until attending this conference.

You guys made a very good point that if we do not report errors, we lose the opportunity to learn. Because when I disclosed this error with my workmates, who also attended this conference this weekend, we developed some questions which we lost the opportunity to answer. We wondered why people are not encouraged to look up medications/procedures that they are unfamiliar with before using them? We wondered why didn’t the pharmacist or Nurse recognise that this medication which is usually given once or twice a day was ordered four times a day and notify someone? Or did they not know that medication was not dosed this way? We also wondered whether our EMR failed the resident by not providing notifications that they were deviating from the standardly used dosages? I questioned whether this incident was noted in the hospital data as a medication error and who should such incidents be reported to in my facility? By not having answers to these questions, it is very likely that this error will happen again and the next time, the patient may suffer a fatal consequence of the mistake. Attending this conference opened my eyes to the fact that it was not just a physician error, it was a system breakdown.

Another good thing that came from this conference was that I learnt to consider the consequences of my actions on patients.  Referring back to that situation that happened in my facility, I now wonder if the family or the patient was told what happened. Because I recall that the patient had severe bradycardia and I would assume that it would have led to a longer hospital stay than planned. To a provider, a longer hospital stay is merely inconvenient and only has financial implications for reimbursement. But some patients need to be at work in order to support their families and extended hospitalizations can be devastating financially.

I could speak on on how transformative attending this conference was on my thought process. I will say that I have come away with a greater understanding on how my actions affect the lives of my patients. Because of this conference, my colleagues and I want to refine our project on reducing medication errors.  The general attitude is that we are residents and that nothing we say or do matter. But that is not true. We as a group are the ones who manage patients in our service and thus we are the ones whose actions directly influence patient outcomes.

The tour of the Arlington National cemetery was particularly moving especially since I come from a country whose entire population is about 350, 000 persons. As Rosemary spoke I imagined going home and being the only person on the island because everyone had died. It really brought home the magnitude of the problem for me.

 

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