Dr Sue Ieraci: When doing your best isn't quite enough

Motivated by a desire to reduce “system problems” and systematic error, the clinical governance workforce has refocused its attention on individual error, and the concept of the “incident”.

So, what (officially) is an “incident”?

The New South Wales Clinical Excellence Commission (CEC) states that “An incident is any unplanned event resulting in, or having the potential to result in, harm to a patient.

The term ‘incident’ is very broad and provides comprehensive information on many areas where improvements could be made.”

For appropriate reasons, the incident notification system has been made easy to access through every hospital computer. Reporting is encouraged; identification of the reporter is not required.

The result is that the manager of each department receives a large volume of reports which require review, investigation and response.

These are “incidents” according to the above definition; they are not all patient care issues; they are not necessarily accurate; the reporter may have misunderstood the situation; or their criticism may be simply wrong.

That’s not the main frustration, though.

There are staff employed whose sole role is to examine, analyse and “manage” these reports.

Rather than looking for overall trends in the database, as the CEC does, these “governors” expect managers to make policy or structural changes in response to every report, so that “it never happens again”.

However, there is no human service in which human error can be eliminated.

There is not one of us who has not missed a diagnosis, failed to document adequately or failed to communicate optimally, even though we all know that we should.

There must be an understanding that not all events are “system errors” and that not all errors can be prevented or even foreseen.

Most frustrating of all is when an error results from being distracted or overloaded with multiple tasks and responsibilities, and the suggested process to prevent that error adds yet more tasks and processes: more documentation, more checks and more tasks.

This adds to an already chaotic workplace. What is needed is simplification.

So, here we are. Don’t forget anything, don’t miss anything, don’t lose your concentration — you may make a mistake. We don’t tolerate mistakes. We’re not blaming you; we just want to make your work even more complex and tedious so we can make sure you don’t make that mistake again.

Posted: 12 July, 2010

Dr Sue Ieraci is a specialist Emergency Physician with 25 years experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. In addition to her emergency department work, Sue runs the health system consultancy SI-napse.