Medical Error & FOAMed

Another interesting week following on from #SMACC2013 and the increasing interest in #FOAMed amongst not just critical care and EM physicians, but the rest of medicine.

First up, the launch of a new website FOAM4GP.com - an idea that a few of us had been bouncing around for a while, in or enthusiasm to bring quality free open access medical education to a wider audience – not least primary health care clinicians.

As time goes on, Minh, Casey and I hope that more GPs will embrace the #FOAMed concept and contribute – particularly registrars and newly-qualified docs who have much to offer.

So – if you haven’t already – check out FOAM4GP.com

Meanwhile, Casey Parker over at BroomeDocs.com has commenced a new series “Lessons Hard Learned” as a series of podcasts.

This is a topic dear to my heart (but sadly, living in a small community and with easily identifiable patients, I dare not contribute content – yet).

The issue of error in medicine was discussed at some length at SMACC2013 – Prof Simon Carley (author of BestBETS.org and leader of successful Team GB in SimWars, as well as a nice chap) spoke well on difficulties of diagnosis in EM. Others spoke on medical error, human factors and checklists…

In the anaesthetic community, the Elaine Bromiley case is often used to discuss crisis management and the dreaded CICO situation. If you haven’t already seen the video, you can watch or download here from the ‘Resources’ section of KI-Docs.com.  However I think that one of the most interesting bits of Martin Bromiley’s discussion is that of uncertainty around the error rate in medicine. We simply DO NOT KNOW what error rates are for our trade.

An old adage is that the only way to avoid mistakes as a doctor is by experience … And the only way to get experience is by making mistakes ! Which is why “Lessons Hard Learned” is useful – it allows sharing of important, personal messages between clinicians with the shared goal of improving patient quality. Yes these are anecdotes, but sharing these intensely personal experiences has an educational benefit.

That said, if we are serious about reducing medical error, the real solution lies in recognising that as doctors we WILL make mistakes. Better to engineer safety into the system, to allow a chance to remedy physician error. Of course in a health system under pressure to churn through patients, with financial and resource limitations and with emphasis on medicolegal channels to pursue individuals when error occurs (rather than a no-fault system), this may be unrealistic. But one can dream…

For what it is worth, my ‘top tips’ on hard lessons are below. They may not be revolutionary, but they are errors that one sees again and again, even in experienced clinicians

  • Don’t ever forget to measure a glucose
  • Consider doing a pregnancy test in any female between 10-50 years of age
  • Respiratory rate is a good marker of ‘being unwell’ yet is often poorly recorded. Ask for the Resp Rate and act if up or down.
  • Trust your instincts. If a little voice is nagging at you, listen to it
  • Never let the sun set on pus
  • Remember that if you are either hungry, angry, late or tired (HALT) then your performance will be affected
  • When you are in a rush, make an effort to SLOW DOWN
  • Just because someone works in a teaching hospital, doesn’t mean that he/she knows more than you. As the clinician on the spot, you are best placed to determine if someone needs to be seen or not.
  • Sepsis can sneak up on you and patients deteriorate with terrifying speed. Look for sepsis. Then look again.
  • Beware the automatic BP reading in a resus – remember to set the frequency of recording at the start of a resus – otherwise you will be falsely reassured by seeing the same rock-solid BP. That’s because it hasn’t been measured since initial set of obs
  • Don’t be afraid to ask for advice
  • Use cognitive aids like checklists and #FOAMed resources
  • It is OK to say “I don’t know” – whether to colleagues or your patients. Dealing with diagnostic uncertainty is challenging, but often things are NOT clear and opening up communication between doctor-patient to acknowledge this and establish criteria for concern/re-presentation/follow-up are vital

Finally, as one wise intensivist said to me “If you don;t know what to do with a sick patient, wait until he/she arrests – THEN you’ll know what to do” – kind of distills all of clinical medicine down into the one algorithm !

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