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Remember; be kind

August 11, 2009

We are working on the memorial efforts for tomorrow, and the tragedy that befell us last week is still foremost in our minds. Tomorrow we will remember what a beautiful and lively person she was. We remembered that today. And yesterday. And every other day, but tomorrow we’ll say the words and think the thoughts together, share our grief, and our kleenex.

Normally I try to update this blog regularly, but I feel like nothing that I say can be as profound as what has happened. Still, for my own sake, I feel the need to try and keep on keepin’ on with it. I also need to further reflect and change in accordance with what I think is right, instead of being a hypocrite. So, that means taking care of myself, and taking care of others – which I haven’t always done.

I recall an incident that I handled poorly in the past, and wish I could go back and change. I can’t, so I’m going to just have to be satisfied with doing better next time.

As a senior medical student, I was on an ER team doing a conscious sedation for a fracture reduction. Assisting a resident and I, was a capable respiratory technician (RT) and a new student nurse. We wanted to give the patient midazolam (a sedative) and morphine (for pain), in preparation for the procedure. The resident said the dose of the narcotic he wanted given, the student nurse pushed some of that drug, and I thought I saw that more had been given than was asked for. But I wasn’t totally sure. I saw that there was no Narcan or flumazenil (the reversal agents for the drugs we had given) on the nurse’s table. They are usually on the table. I could only muster a quiet  “ah, ahhhh uhhh” but did not speak up. The patient went apneic (stopped breathing) and I helped the RT manage the airway. The patient woke up, started breathing, and the fracture had been set. Everything was okay. But not really.

I should have spoken up more. The nursing preceptor should not have left the student hanging. The student should have ‘fessed up to the mistake if they noticed it, or recognized that they weren’t yet adequately trained to do what was asked. We had the safety measures in place in case of respiratory depression (exactly what happened), but it could absolutely have been avoided. The worst part is, that no one debriefed that student nurse. And no one spoke with the preceptor either.

As a person who was not in a position of authority, it could have been me that spoke with that new nurse. I would hope my also being a student would make it more collegial and less condescending. I should have taken her aside, and asked what she thought had gone wrong and why? I would have told her that yes, she screwed up big-time, but that everything was okay now. We were prepared for such an incident, but it could have been and should be avoided. We should have discussed that she had to do her end of the preparation too; there’s good reason to keep the reversal agents close by. I would say, “to avoid making serious errors, you have to feel comfortable and not be shy about asking for help when you need it. It’s not safe to do anything you aren’t trained for, unless you supervisor is standing with you, training you how to do it in that moment.  Be ready to  tell someone if you forgot what to do or think you’ve made a mistake, so that they can help you correct it. We all make mistakes. And we all help each other fix and prevent them.”

Okay, so I probably wouldn’t actually have lectured her, but asked her a lot more questions about what she could have improved, what barriers she was facing, and then went on to discuss how she could navigate around them. (eg. “my preceptor is too busy – another nurse or doctor may be able to supervise you briefly; my preceptor is not approachable – talk to them about how best to approach them or find a new preceptor, etc.). This is probably not the best way to handle it, but having never debriefed anyone, I really don’t know a better way. I expect we will be getting some training in this, and I could sure use it.

It’s hard to reveal our mistakes to others, as it renders us ashamed and maybe we even feel weakened by it, but as we have so painfully seen, sometimes we are our own toughest critics. When solely dealing with others – and I would never have believed this as a kid – it’s true that taking responsibility for one’s actions simply makes life smoother (N.B. Bill Clinton). However, when dealing with ourselves, well, I don’t know what to say.

Be kind.

2 Comments leave one →
  1. August 12, 2009 3:11 pm

    Unfortunately it is anathema in medicine to discuss mistakes. I don’t know much about Canada, but here in the US admitting a mistake could lead to a catastrophic law suit in which the healthcare worker (usually a doctor) is held personally and financially liable for the patient’s life. People expect us to be 100% error free, and that just isn’t humanly possible.

    I have not (that I am aware of) yet made an error that directly resulted in a death, but the possibility of it keeps me anxious every day I work. I don’t know how I might react if someday I am called to a courtroom and blamed for ruining someone’s life. It would be devastating. I can understand what your colleague was going through.

    I continue to pray for her family.

    • August 13, 2009 6:26 pm

      We need to decrease the stigma of medical error so that errors can be discussed (and maybe more will be prevented if we know how and why they happen). As I responded in the other post, we are less a litigious society. If Person A brings Person B to court and loses, Person A will have to pay their own legal fees as well as those of Person B. So people really only go to court over the really serious stuff.

      We all wish to avoid complaints to the College, but the majority of these are related to beside manner or miscommunications and can often be worked out without involving the law. Many personality disordered patients will also lodge complaints, and after investigation, many of these complaints are found to be lacking.

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