This is the eighteenth #WILTW (and a little delayed due to working the weekend!)
How many times do you need to experience something for you to learn from that experience? In medicine health care professionals will often refer to ‘sentinel’ events. A clinical incident which has forever changed their practice:
“I will never forget the patient who…. ”
These events often have a patient safety element to them, with harm or near harm, unfortunately occuring. It is the seriousness of the outcome making the event the more memorable. A catalogue of these stories by senior health care professionals can be found in the handbook “Medical Error“. It is shame that these sometimes tragic events need to occur to ingrain key actions and principles in people. But how do you make sure you don’t repeat mistakes when there isn’t a significant outcome to an error you have made? Take this example; males presenting with abdominal pain could actually have a problem with their testes. Failure to examine the scrotum may miss a testicular torsion (twisting of the testicle) resulting in the patient having to have it removed. However it would be possible to examine hundreds of patients with abdominal pain – never examining the testes – and no one ever coming to any harm because none of them had testicular torsion as the cause of their pain. If no-one ever audited your notes and fed back to you may never realise you were missing out this important part of the examination.
I am reminded of this as my second ever post on #WILTW was about the importance of clinical guidelines and how sometimes guidelines may trump gestalt. Last week I was involved in a similar case demonstrating following a tried and tested pathway was probably better that thinking ‘I know best”. Although ultimately it wasn’t a black and white issue, and there was no harm to the patient, I was left with a real sense I hadn’t learnt my lesson. In some respects cognitive errors that involve the interplay between guidelines and gut instinct are not great examples of sentinel events. I am though left with the feeling that despite blogging publicly about “what I had learnt this week” a couple of months ago maybe I had not learnt anything at all? Or maybe the event opened my mind to note when I am making similar errors. Maybe this post was only possible because of that previous experience? Learning might not be so concrete as to ensure when this event happens you will always do this. It’s probably a little more subtle than that. At the end of the day I hope this catalogue of reflections will always inspire me to think that little bit harder about the consequences of my actions.
What have you learnt this week? #WILTW