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WHEN DO SCIs HAPPEN?

The world of healthcare is dynamic; it involves risk and consequently, clinical encounters and judgements can never always be safe. There is a constant and balancing of risks by clinicians in each clinical context in which they practise. Risks are balanced to maximise benefit and minimise harm to the patient. This means that healthcare is a context in which clinical incidents will inevitably occur. In a Norwegian study, 88 % of doctors indicated that they had made mistakes that could have had clinical consequences and 71% reported that they had made mistakes that had consequences for patients (Paulsen &Brattebø2006).  This demonstrates that clinical incidences are a common occurrence. They are not undertaken deliberately, but at some point, in your career, you will probably be involved in one.  Ask your colleagues, including other healthcare professionals, if they have ever been involved in a clinical incident.  It can be very cathartic to share difficult experiences with people you trust as sometimes the experiences can stay with you and possibly undermine your confidence and enjoyment of your career. When you are supervising a junior member of staff, for example a medical student, tell them in your first meeting that you want them to come and find you if they are ever involved in a SCI. Share the mistakes you may have made in the past and explain how grim it made you feel and how you dealt with it, learnt from it and moved on.

 

Human Factors in patient safety: Dupont’s Dirty Dozen

From a patient safety perspective, medicine has borrowed heavily from research and analysis undertaken in the aviation industry. A critical list of factors commonly involved in human errors in aviation, but which also apply to medicine has been named as ‘Dupont’s Dirty Dozen’.

These twelve factors, consistently involved in human error, are:

Lack of Communication	Lack of Resources
Complacency	Pressure
Lack of Knowledge	Lack of Assertiveness
Distraction	Stress
Lack of Teamwork	Lack of Awareness
Fatigue	Norms

You can learn more about Dupont’s factors and how to manage them in the pandemic in a webinar by Maria Crilley (2020) Human Factors “Dirty Dozen” and Covid-19 webinar https://www.youtube.com/watch?v=hERzwDaW49k

 

Action Point 3: In this exercise:  Reflect on your clinical experiences to date to complete Column 1. In Column 2, rank from 1-10 (1: being something which you have influence over and 10: being something over which you have no/limited influence). Organise the results in Column 2 On a separate sheet, devise an action plan for your top three (3) e.g. lack of resources – if there are insufficient staff, complete a Datix, inform your Line manager and keep a copy of the emails sent outlining your concerns.

CLICK THE TAB AT THE BOTTOM OF THIS PAGE TO ACCESS THE DIRTY DOZEN EXERCISE TABLE

 

In the NHS, it has been found that SCIs tend to occur when doctors:

• feel pressured by time/ deadlines
• are multi-tasking
• are working ‘out of hours’
• are involved with prescribing
• undertake routine procedures
• are in new, unfamiliar environments

The most experienced of doctors can make mistakes – and the brave ones share their experiences for the benefit of the wider medical community. This reflection is from Andrew Miles, Consultant Surgeon, and a Director of Professional Affairs at the Royal College of Surgeons (Miles 2016):

I was drawn into an error by a patient who lived at the same address as his son, who had the same name and he hadn’t noticed that the date of birth on his appointment letter was for his son, not for him. As a result, he attended an outpatient appointment expecting to see orthopaedic surgeon about his knee but didn’t complain when I enquired about his haemorrhoidal symptoms and then offered to band his haemorrhoids as he was having such trouble with them. In fact, he had had troubles with his haemorrhoids for years and was very grateful, if a little surprised, to have them treated. Times have changed since then and nowadays, I would have checked his date of birth and realised that this patient was in his sixties and I was expecting a patient in his forties.

 

A very human and honest overview of human factors related to doctors can be seen in this YouTube video by A&E Consultant, Dr. Rob Galloway https://www.youtube.com/watch?v=ChGEf159EsU

 

Action Point 4:

How close have you come to being involved in an SCI?

What were the circumstances?

What did you learn from the experience?