In his latest blog, Ehi Iden, hub topic lead for Occupational Health and Safety, OSHAfrica, discusses the importance of documenting and learning from patient safety incidences. Using a fictional story to draw parallels from, Ehi highlights how accountability, leadership and reporting incidences will help us keep staff and patients safe.
Let’s start with a story I was once told…
There once was a very successful farmer who hired many people to work on his farm; at a glance, you could see countless heads of men and women tilling the ground. He grew very rich. The wealthier he became the more people he hired. His farmland kept increasing every year until it got to the boundary of a river.
Although there were many workers, the farmer knew everyone by name and was able to account for them on a daily basis. However, over time, he noticed some workers who came to work could not be accounted for – they went missing. The farmer became worried. He realised those workers who went missing were last seen tilling the ground close to the boundary of the riverbank. He closely observed the riverbank and on one fateful day he saw a wild sea creature come out of the water towards a worker who had his back to the river. Being a good hunter, the farmer positioned himself and watched closely. When the sea creature got close to the worker the farmer fired his gun and killed the creature before it could harm the worker. The workers saw this and realised this creature has been responsible for the sudden disappearance of their colleagues over the past couple of weeks.
The farmer realised that many dangerous creatures lived inside the river behind his farm and that this had left his workers unknowingly exposed to a very high risk. The farmer got rid of the sea creature, moved his workers away from the riverbank and reassured everyone of his continuous responsibility towards their safety. After, the farmer wrote down what he saw; he titled it ’The Minutes of the Minute’.
Workplace health and safety
When I reflect on this story, I realise we all have ‘The Minutes of the Minute’ in workplace health and safety, in patient safety and in quality improvement, but they are usually not documented for us to review and learn from. Accident and harm happen on a daily basis but we hardly ever have clear records of what led to the harm. We have become so used to such harm that it is often overlooked and seen as a part of the system. Every near-miss is a potential lost life if not reviewed, checked and controlled, but most of the time we see them and overlook them. No one ever takes the minutes of the minute; we never know the details of what led to the near miss. When it happens next, it’s no longer a near-miss but a clear harm to patients.
Until such a time where everything that happens every minute within healthcare systems becomes our collective concern, patient safety will only be an illusion that we will all continue to struggle to fully understand. We need the right kind of leadership. We need hospital boards that are not made up of armchair rocking and profit-minded investors, but that are patient-centric, compassionate and empathetic modern-day thinking people. We can only profit when we get safety right: the lives we save, the families we keep together, the smiles we put back on the faces of patients and patients’ relatives. These are unquantifiable streams of profit that come with a sense of fulfillment.
Going back to the story, the farmer knew everyone who worked for him despite the huge population of workers. What does this tell us? Whatever is important to you, you create time for it. You cannot manage what you do not understand. Every healthcare worker differs and may need to be managed in different ways. The farmer was observant enough to notice some of his workers were missing, even noticing where last they worked before they went missing – this is accountability. We may not notice some sudden obvious changes in our colleagues or employees behaviour – for example, they may become toxic within the patient care team, and it will only take time before such toxicity in behaviour leads to a patient being harmed.
Every near-miss, adverse event and incident should be followed by a post-mortem: investigating what happened, why it happened and adjusting the systems towards mitigation. This is learning from incidence.
Patient safety as a goal
If patient safety is indeed our goal, then every member of the healthcare team needs to look out for each other and offer mutual support. Over working healthcare professionals is the new risk in patient safety but looking out for each other and mutual support is an effective antidote. We need to encourage reporting with an honest and clear motive – not because you want someone victimised or blamed but because you want to create a learning curve out of the situation for system improvement. This culture of honest reporting without blame creates a healthy and safe system for both the patients and caregivers alike.
If healthcare leadership is all about sitting in boardrooms you are cut off from reality and are ignorant of what happens at the bedsides. The farmer in the story did not find out what was responsible for his workers disappearance by sitting in a big rocking chair dishing out orders, he went to the centre of the risk. Good leaders lead from the front. You can only see so much when you stand back; the hidden things become visible only when you move closer. Seeking outside help may not fix your healthcare systems; if you look inward and closer at the risks, you will find solutions. This was what the farmer did and today we have “The Minutes of the Minute” as coined from his story.
We must remember, what is not documented is easy to forget. When you take down the ‘Minutes of the Minute’, you are documenting the highlights of the key issues that happened within the minute of the act that led to patients’ harm or the accident. We will always need this to learn from, to create an invaluable learning experience towards building safe systems that provide for patient safety.
About the Author
Ehi Iden is an Occupational Safety, Health and Wellness Consultant with over 20 years’ work experience spanning through healthcare management, patient safety improvement and Occupational Health and Safety Management.
He is the founding CEO of Occupational Health and Safety Managers (OHSM), a Head of Faculty at OSHversity and President, OSHAfrica.