End Notes
Error Out
Shining light on a mistake provides an opportunity for many to learn.
By David W. Moen, M.D.
I made a poor decision two years ago when I was medical director of our emergency department that set the stage for an error. It happened when one of my partners placed a chest tube in a female patient with a collapsed lung. The tube did not fully reinflate her lung, even though a chest X-ray showed it to be well-positioned. Frustrated, the physician told the patient that her lung had improved but that the tube was not functioning properly. He asked a surgeon to see her, hoping the surgeon could help him figure out why.
The nurse caring for the patient was sure that a clear plastic sheath that should have been removed prior to insertion was covering a portion of the tube and interfering with its function. But knowing that the surgeon was on his way to see the patient and seeing that the patient was stable, she decided not to share this information with the physician.
The patient was moved from the ED to the ICU. When the surgeon arrived, he discovered the problem and replaced the tube. The patient’s lung inflated immediately. A nursing supervisor in the ICU suggested the surgeon call me about the patient’s status. He told her he would talk to me later but that he really wasn’t interested in “getting my partner into any kind of trouble.” He placed the old chest tube with the sheath still attached in a plastic bag and put it in his locker to show it to me later.
The nursing supervisor called me the next day and told me what had happened and that she thought it was unlikely that the surgeon would call me. She and I had worked together over the years, and she trusted that I would respond appropriately.
When I entered the ED that afternoon, I heard nurses murmuring about the error. They were questioning the competence of my partner. It was clear they were making assumptions about what had happened.
I felt nauseated. A bright light had been cast on personal dynamics within our ED that were unsafe and destructive. I could not believe what was happening. I prided myself on building a culture of teamwork and respect. This felt like a failure. I knew I needed to act and that my actions would be critical to bringing the ED staff to a safer level of performance.
After more fact-finding, I called my partner at home. “Remember that patient you put a chest tube in the other night?” I asked. Of course he did. He told me he had lost sleep over the incident and was still unsure what had happened. I told him that no long-term harm had been done but that an error had taken place that I thought we could all learn from.
I shared what had happened during the last 36 hours, including the nurse’s and surgeon’s discomfort about approaching him and me. I told him I was concerned about his reputation as a clinician and that we needed to be open about what we had learned from this incident. We both agreed this could create a safer environment for everyone. I also told him I was ultimately responsible for what had happened, as I was responsible for training physicians to use the equipment in our ED. I explained that two years prior, the ED manager had shown me the new chest tube catheter. I noticed the tube had a clear plastic sheath on it and thought others would as well. What I didn’t realize was how similar the new tube was to the one it replaced, which had no protective sheath. Now I realized I had missed this. I apologized to my colleague.
The following morning, we met in the trauma room. A few nurses joined us. I pointed out the similarities between the old and new catheters, explained that I had not suspected this might be a problem, acknowledged that this was an oversight on my part, and explained that there would be changes in order to prevent a similar mistake from occurring.
I then spoke with the nurse who had discovered the problematic sheath about my interest and that of the involved physician in learning from this error. I told her that he wanted to know why she hadn’t told him about the sheath that night and what he needed to do to be more approachable in the future.
Everyone I spoke with agreed that we should go public about the experience, so we sent a memo to the staff that explained what had happened and who was involved. I took responsibility for the error.
We ultimately began training staff to use the equipment using simulated patient technology. We also started encouraging staff to speak up if they saw something that didn’t look right. This has resulted in higher safety scores on annual surveys and a perception of improved performance on the part of team members.
Too often, we seek only technical fixes to failures in our systems. In this instance, a technical fix directed at preventing one doctor from making this error again would have been a lost opportunity to prevent others like it from occurring. Looking deeply into our errors sometimes reveals our own failures. I have learned, however, that such discoveries make our work environment safer. MM
David Moen is medical director of care model innovation at Fairview Health Services.