The anatomy of error

There are few of us who do not fear failure. Even with the best plan, the best people and solid execution, mistakes will happen. In pharmacy, we refer to these mishaps as ‘medication discrepancies’, forerunners to the dreaded ‘medication incidents’.For new pharmacists, once they’ve completed their degrees and written their licensing exams, everything becomes so real. There’s a professional institution to uphold, and high standards. 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?)By my estimation, it takes new grads up to six months after licensure to begin feeling comfortable with their style of practice. They feel less paranoia about making mistakes and maybe don’t feel the need to quintuple-check everything.Mistakes happen to everyone. They always will. Being human, we attach a negative emotion to each mistake that 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 made my share of mistakes, and I’ve counselled 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 CashMr. Cash’s philosophy 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 never intentional. Discipline is usually reserved for instances when someone willingly sabotages a system, or is neglectful in maintaining 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 and doubt. Whether at the beginning of a career or at the end, that heightened awareness sometimes works against you, leading to more errors. 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 forever heavily researched. But dwelling on it, and putting extra effort into preventing a similar mistake, perhaps increases the chance of missing something else. The pattern can spiral, and owning mistakes is stressful at the best of times.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 up a guard, that may prevent us from investing ourselves in all of our subsequent interactions. And those other folks need our best as much as the person affected by the error.Expanded scope responsibilities virtually ensure that we will make errors in new ways. We could misinterpret a lab value, perform an injection that doesn’t go as smoothly as we’d like, or prescribe for a minor ailment and later find a missed red flag. If we stay true to ourselves and to our capabilities, we will use these errors 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.Devin Covey is a pharmacist and author of PharmAspire, a blog exploring “The practice of pharmacy, on your terms…in your terms”.

The anatomy of error

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Devin Covey