Another insightful day

Today another lived experience was shared. It was that of a widowed husband, this time from the UK, who shared the experience of his wife, undergoing what was a routine surgery but ended up not making it to surgery and having a fatal consequence as a net result of an adverse event and subsequent accrual of system failures, particularly those of a human factor nature. This brings to the light the many human factors that we continually witness in practice, which may be harmful especially when aligned in particular contexts, notably in situations that are unfamiliar or deviate from the norm. One of the things I particularly reflected on is how we as humans are fallible to task focus and makes us become situationally unaware. It is something we need to keep in mind when retrospectively analysing incidents. Even I have to admit that I have been unaware on occasion. It is important to be conscious that we can become like that. This emphasises the importance of teamwork, communication and dynamics, which are able to overcome authority gradients and their pertinence to allow goals to be met.

In analysing the incident, we used the HEAPS tool and I think it was a good tool to help debrief without a culture of blame, an area I think organisations can work towards if change is to come about at a faster pace. The other thing I liked today was understanding the communication styles that exist and where we sit on the spectrum and need to transition to in light of specific situations. It helped me to understand my behaviours better and what I needed to do to be safer in an unsafe situation where appropriate and possible. This together with the PACE tool for graded assertiveness were quite useful and insightful in recognising the human factors that exist and can breakdown optimal healthcare delivery. This would have been such a useful tool to have learnt in my pre-clinical years because they are skills I would have found useful and applicable in previous experiences during my clerkship, specifically the principles of probe and alert would have been a useful tool, especially as I consider myself as a cooperative communication predominant personality and can find it challenging to move to assertiveness. These are tools I would have found useful when also practising pharmacy and especially having to challenge decisions where there was a strong authority gradient present.

Another tool that would have been useful to have known beforehand was what to consider when working on CQI projects and I learnt many things from sharing with others about the types of projects they have engaged in.

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