Think about it this way: If you’re stocking cereal on a supermarket shelf and one box gets put in the wrong place, it’s not a big deal. But, if you’re working in a hospital, where thousands of needles are used every day, and one nurse or one physician gets stuck with a needle, it’s a huge deal. That one nurse or doctor can be exposed to diseases such as Hepatitis C or HIV. Working stocking shelves in a supermarket (which I have done) is not a high risk pursuit. Delivering health care is.
Other high risk industries like nuclear power, for example, teach their people to be mindful. They caution their people about becoming complacent and about ignoring little things that are wrong because they know that these little things can begin to add up.
“It’s okay to ignore the alarm…it’s probably that the lead has come off;” “It’s okay to let the patient leave before the Anesthesiologist has checked him…they frequently do and no patient has suffered before because of it;” “It’s okay not to put on protective eye wear before I put this NG tube in that may make the patient cough…I've done it tons of times before with no ill effect.”
The acceptance of these small deviations eventually add up to something bigger.
Nuclear power and commercial aviation have taught their people to be preoccupied with failure. They teach that the best way to avoid catastrophic failures is to look for them developing so as to head them off. They teach their people to follow the design and to be alert that even the best design may fail.
In health care, we often drift and allow failures in following the design because we assume that things will go ok. How many times do healthcare workers fail to use protective devices because they are usually not exposed without them. How often do surgical teams pass sharp instruments using incorrect technique because they have never been stuck before? Before pilots began using pre-flight checklists, most flights took off safely…but some didn’t and many people died because of this. Now, all pilots use the checklists every time and they are still mindful of things that may signal that something isn’t right.
Recently, we’ve had a couple of needle stick injuries where our people assumed that their colleague had disposed of a needle correctly. The colleague, however, did not. They became distracted and left a needle on a bed or on a stand and it became “hidden” in sheeting. Then, another staff member came in, and assuming everything was safe, grabbed for the sheet to throw it into the trash. But when they grabbed the sheet, there was a needle wrapped in its folds and this individual was stuck.
Telling people to always properly discard needles does help, but it cannot get us to higher levels of reliability and safety. We must also be mindful and have this preoccupation with failure and change the way we see our work. Rather than assuming all is well, we need to assume that danger is lurking nearby. If we are mindful that there may be a needle in the sheeting we’re about to throw away, we’ll deal with this sheeting differently and pick it up differently. This concept of preoccupation with failure is something we need to adopt at GBMC. I welcome your thoughts and comments.