Spilled Milk: An Investigation.

Be careful with that. Don’t spill it!

A few minutes later, my daughter’s tiny, sweet hands, place the giant cup down on an awkward angle beyond her dinner. The cup rocks back and forth and seems to settle on the tip of the fork. Phew.

And then it topples over, onto the table, and over the iPhone. A white wave washes past my plate, onto my lap, and drips down to the floor.

There are two aspects about this story that remind me of errors in the hospital, one is the early response, and the other is the steps to take to prevent recurrence, the late system response.

The initial response involves  knitting my brow, grabbing everything out of the milk’s path, and yelling, “I knew that would happen, this is your fault!” The Confrontation, pointing of fingers and laying blame.

Parents are very good at the warning. Don’t climb there; you’re going to fall. Watch that cup, it will spill. Don’t jump on the bed; you’re going to break…. Oops.

We say these warnings as much to protect our kids as to have that “I told you so” in our back pocket. We become the personification of an alarm, and my daughter learned a long time ago the reaction: ignore. The home version of alert fatigue.

An error, a “never spill” event, occurred so let’s look at the system response. The next step will be a root cause analysis to determine how this could have been prevented.

I see a table covered with meal plates, appetizer plates, chips, multiple utensils, and hence the table cloth is buried from view. The waiter brought over the same glass I received, and my hands are three times the size of my daughters. The glass had no lid, and was filled to the rim. I gave an ineffective alert as my daughter was glancing at the TV over my shoulder. The spill was inevitable.

The system is the major player in the war on quality. Treating mistakes as system errors is part of our Quality 101, yet I am often surrounded by people and measures that aim to identify and penalize the individual.

Ok, so the milk is all over my lap, the iPhone is on the fritz, and I’m on my last straw. How do you respond as a parent? Blame the individual, as above?

Of course not. Yelling leads to shame, to crying over spilled milk, to fear of communication, and we uncovered that this was a system error, an accident.

We employ hugs and laughter for these type of accidents. We have a traditional serial knocking over of items or glasses in the face of one spill. It was an accident. We laugh, smile, clean it up, and admit that it wasn’t done on purpose. Let’s work to prevent it from happening again and hug it out.

We learn quickly as parents that not getting upset over these inevitable accidents is the right way to respond to these scenarios, yet do we follow the same logic in the hospital? Do we avoid shame in the hospital?

This article by Pronovost (a must read) had me thinking a lot about how we approach a just culture in the hospital, and whether one really exists. It reminds me that we should be treating each other with love and compassion, as equals in the fight against preventable errors.

It’s magical when an adverse event is treated with love instead of guilt, shame, anger.

I recall vividly the case of the disappearing patient. Another ordinary day in the hospital. I stopped by to see Ms. Barnaby, who was in the hospital with mild diverticulitis and some bloody stools for 2 days. She was ready for discharge, but reported some shortness of breath overnight, and was tachycardic throughout the night. She felt fine now she said and wanted to go home, but I discussed getting a CT of her chest before discharge. She was adamant about leaving, and I reassured her she can likely leave, but to wait for the imaging results.

Despite admonitions of “I better get home today, Doc,” she agreed, but still began to pack up, including the flowers that accumulated in her room. I discussed with the nurse that if the CT is ok she can go home, and I would have her discharge paperwork ready.

A few hours later I returned to discuss the results. She was going to be disappointed. A blood clot.

I took a deep breath and walked in to tell her. And found a well-made bed, clean sheets, no flowers, empty room.

Where did she go?

One version of the immediate response I see too often in the hospital is that Confrontation. The doctor gets mad, seeing the spilled drink, and begins to point fingers.

I picture numerous attendings in my mind, enraged at an order they wrote not carried out the right way, swarming out looking for the cause of the error. Looking for someone to yell at.

When I did find the nurse, told her the CT report, and asking what happened, she looked aghast. She was expecting to be shamed, and started apologizing profusely. That look scared me as much as anything. How have physicians created a relationship with nursing that they are afraid of us?

We calmly discussed the situation, clearly there was an error in communication, and I understood the error in my fuzzy discharge instructions. The patient pushed her way out once the CT was done. “He told me I could leave after that CT.”

We called the patient at home, and she was back in her room within an hour. She was still breathing slightly labored, heart rate elevated, but understood the situation, and was started on lovenox ASAP.

That was 8 years ago. The nurse and I talk about the story periodically. She is one of my favorite colleagues to work with, one of the best nurses in the hospital. She remembers it vividly, as do I. She geared up for yelling, write ups, bringing this to the manager, getting fired, leaving the country. Instead, the opposite happened, we both improved our communication regarding discharge instructions, and spread the gospel of better closed loop communication.

We treated quality with love. No guilt. No shame. But love.

As I mentioned in my last post, and will allude to in my next post,  Donabedian told us all that, “The secret to quality is love.”

We need to work together, find the holes in the system and fix them. Understand we are all working together in our duty to patient welfare.

Accidents, mishaps happen. If we have a just culture, our response should be with respect and compassion. If we don’t have a just culture, we need to work to create one.

The nurse doesn’t let other docs get away with misbehaving. That Confrontation and finger pointing discourages communication, leaves a black scar in the middle of the conversation, and lets the spilled milk sour.