The Anatomy of Error

Quick show of hands…How many of you are perfect? 

Everyone? Well I agree you are all perfect in your own ways but I really need to get this post started.

Okay, how many enjoy messing up?

 

There are very few people out there that don’t have a fear of failure. For every task there’s a plan, and for every plan there’s an action. The action produces results. This oversimplification leaves out one crucial element: expectations. Every plan has an expected outcome, or at least it should. Some plans are doomed to fail. They fail if they aren’t addressing the task, are too complex, or don’t have realistic expectations worked into the plan itself.

Even with the best plan, the best people, and solid execution, mistakes still happen. In the world of pharmacy, we refer to these mishaps as ‘medication discrepancies’, forerunners to the dreaded ‘medication incidents’. After new pharmacists have completed their degrees and written their licensing exams, everything becomes so real. There’s an professional institution to uphold, and standards are high. Every slip of concentration may result in a missed interaction or an inappropriate dose that holds potential for harm. If that mistake comes back to you, panic can set in:

Will the person sue me?

Will I be disciplined?

Will I be fired?

All of these questions rattle around and try to defeat your resolve. By my estimation, new grads take upwards to 6 months after licensure to begin feeling comfortable with their style of practice. They feel less paranoia about making mistakes and maybe don’t need to quintuple-check the things they do.

Mistakes happen to everyone. They always will, and the human condition will manage to attach a negative emotion to a mistake each time one occurs. The feeling of letting a patient or teammate down is bad enough, but most of the time, you’re letting yourself down. That’s the one that really hurts.

I have had my share, and I’ve counseled others who have been unlucky enough to experience an error fallout. My approach is summed up by the legendary John R. Cash:

You build on failure. You use it as a stepping stone. Close the door on the past. You don’t try to forget the mistakes, but you don’t dwell on it. You don’t let it have any of your energy, or any of your time, or any of your space.

Johnny Cash

 

For someone who wrote well-known songs such as ‘Ring of Fire’, and ‘Folsom Prison Blues’ (neither bringing to mind the imagery I’m looking for in this post), the above quote is perfect for any situation.

To become a health professional, there has to be a genuine desire to help people, and ensure no harm comes to them. Mistakes that may result in harm are not intended by anyone involved. Discipline is usually reserved for instances when someone willingly sabotages a system, or is neglectful in their maintainance of a system. Once someone has accepted that mistakes happen, addressing the circumstances that led to the error will help prevent it from recurring.

For some, that personal failure is a lot to handle. It can create anxiety, it can create doubt. At the beginning of a career or at the end, that heightened awareness sometimes works against you and more errors result. Why? My theory is that the focus sharpens on the aspect of the process where the error occurred. Wrong strength on a medication? Next 100 times, we’ll be extra vigilant to confirm with the doctor. Missed interaction? Like a branding iron, that drug-drug combo will be etched in the brain forever, and similar ones will be heavily researched from that point on. By dwelling, and putting that extra effort to prevent a similar mistake, perhaps a wrong doctor is missed, or the label instructions are vague. It can spiral, and owning mistakes is stressful at the best of times.

Circling back to the genuine desire to help people, it’s important to remember that we help hundreds of people every day. Errors are and will be a part of life, but if we own up to them and help minimize any impact on those affected, we can show that we care. If the uncomfortable interaction causes us to put a guard up, it may prevent us from investing ourselves in all of our subsequent interactions. Those other folks need our best as much as the person affected by the error.

With expanded scope responsibilities, we will make errors in new ways. We could misinterpret a lab value, perform an injection that doesn’t go as smooth as we’d like, or prescribe for a minor ailment and later find a missed red flag. If we stay true to ourselves and our capabilities, we will use them as stepping stones to constantly improve the quality of care we provide.

Dissect the anatomy of an error. Understand it. Control it. Learn from it. Move on from it. You will be better for it.

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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About Devin Covey

A proud member of the pharmacy profession since 1997, I have a passion for people and helping them thrive. Interests include writing, singing, musical theatre, and biking around my home province of Nova Scotia, Canada.

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