I have spent the last couple of days in hospital having had my appendix removed. My experience of the hospital was fantastic with a high level of care shown by all the staff with whom I came into contact.
Last evening I witnessed an event that displayed integrity and courage, while also highlighting that serious mistakes can be made even in a well run hospital.
At about 8:30pm a senior nurse came in to speak with an elderly gentleman with whom I was sharing my ward. She informed him that he had been given someone else’s medicine an hour earlier. She told him that she had checked with his doctor and that there weren’t any issues regarding side effects with the incorrect medicines that he had taken. She also apologised profusely for the error.
From my perspective the nurse showed courage and integrity by admitting the mistake, initiative by checking with the patient’s doctor before informing him of the mistake and she also provided a genuine apology.
This experience got me thinking. In a hospital it would seem that giving the wrong medicine to the wrong patient is a fundamental error that shouldn’t occur. It would appear that human error was involved. Six Sigma was a system that was introduced at Motorola as a way of creating a culture that minimises such fundamental mistakes. Six Sigma officially translates to 3.4 mistakes every 1 million efforts. I’d like to think that, at the hospital where I have just spent the last few days, the mistake that I experienced was one of the 3.4 in one million!
So, the question for you is, “What are the fundamental errors that you should be minimising? What systems do you have in place to ensure that human error is minimised?” Even a short stay in hospital can provide opportunities for reflection and improvement. I’m certainly reviewing our systems and processes in the context of this experience.
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