Mistakes can be prevented

Published 27.11.2015

Mistakes can be prevented

Patient safety has only recently become topical in health care.

– I have had to look in the mirror myself. Why have these issues not been taken care of earlier? says Jarmo Karpakka, Chief Medical Officer at Mehiläinen, a leading private provider of health care and social services in Finland.

According to Karpakka, patient safety is similar to any other new and unfamiliar task. At first, you refuse to believe in it, then you start to think whether it might be possible and in the end you wonder why we didn’t do it a long time ago.

– In particular, physicians tend to take discussing patient safety as criticism of their professional competence, Karpakka says.

Model from air traffic

Karpakka compares patient safety with aviation safety and points out that medical professions are lagging behind in terms of safety.

– Aviation safety is systematic. Why isn’t patient safety?

According to Karpakka’s briefing, documented procedures, control measures, task lists and checklists as well as working communications practices improve both aviation and patient safety. We know these measures through aviation safety but, for example, surgery task lists and checklists have been shunned.

– Surgeons were against using task lists and checklists. They considered lists as introducing restrictions to their autonomy. Why on earth? In air traffic, everyone agrees that safety comes first.

Incorrect information

All mistakes cannot be avoided, no matter how impeccably everything is done. For example, when taking samples, the risk of nerve injury and hematoma is always there even when everything is done perfectly.

– A common denominator in laboratory accidents is incorrect information. Therefore, patient identification is of the utmost importance. The name is not enough, confirming the date of birth as well is an absolute minimum.

Although incorrect information and incorrectly identified patients are not always a danger, incorrect data invariably means additional work and extra costs.

Not who, but why

Being in a hurry is a plausible excuse for mistakes. However, Karpakka does not think so.

– Could it be a case of bad planning?

When a mistake occurs, it does not help to go after the culprit. The question to be posed is, why did it happen?

– Especially earlier, it was common to focus on finding who had committed the mistake and once that person was found, the mistake was swept under the carpet by claiming that the person had done his or her best. Actually, the workings of the system should be analyzed to find out where there is a flaw that made it possible for the mistake to occur and what could be done to prevent it from happening again in the future.

– Employees need to have the courage to bring the subject up, if they find that something is not quite clear. Then the matter needs to be discussed together and corrective actions need to be taken.

Management of the organization should take responsibility. Management needs to ensure that there are adequate resources and proper working conditions.

Kaikki lähtee organisaation johdosta. Sen tehtävänä on huolehtia muun muassa riittävästä resursoinnista ja työolosuhteista.

Should mistakes be brought out into the open?

As mistakes cannot be completely avoided, it is essential that we learn from them. According to Karpakka, focusing only on correcting mistakes without finding out the reasons actually prevents us from learning from our mistakes.

Another hindrance for learning is in cases where people do not know what they should and need to report.

– Close calls should also be discussed. They present learning opportunities as well.

Moreover, people get used to mistakes and are ashamed of them and therefore management culture is of the utmost importance.

– Management culture needs to be such that it allows for issues to be brought up and discussed.

Text and photo: Hanna Hyvärinen

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