Three years ago I began working with Susan McIver on a book about Canadians who had endured personal tragedy as a result of medical errors. After the Error: Speaking Out About Patient Safety to Save Lives (April 2013, ECW Press, Toronto) tells the stories of these patients and their efforts to prevent similar suffering of others.
The book provides numerous examples of what has been done to promote safer health care and reminds readers that errors continue to devastate lives, despite increasing efforts to prevent them. The latter chapters offer information on how to prevent errors when making end-of-life decisions, how to work with the media and how to organize large amounts of information such as medical records to facilitate investigations. The final chapter offers insights into medical malpractice.
During my 34 years as a registered nurse, I worked in neonatal intensive care, surgery, psychiatry and residential care and had a special interest in palliative care. I studied nursing at Vancouver General Hospital and English at the University of British Columbia. The diversity of my nursing experiences and skill as an editor complemented Susan's background as a community coroner in British Columbia and a professor and research scientist in the basic science section of the Faculty of Medicine at the University of Toronto.
In preparing After the Error, I was naturally drawn to the role of nurses associated with medical errors. I was proud of the behaviour and accomplishments of some nurses and my heart went out to others who found themselves in difficult situations.
The response of a group of British Columbia nurses to the death of an elderly woman in February 2000 was a proud moment for the nursing profession. The woman died 15 days after entering hospital for elective hip surgery and the coroner’s report released two years later revealed disturbing deficiencies in 10 areas of care. Immediately, members of the Registered Nurses Association of BC (now the College of Registered Nurses of BC), assisted by a representative of the health region, began working with the nurses at the hospital where the woman had died. In 2003, this group launched the Acute Care Geriatric Nurse Network (ACGNN) and subsequently the Geriatric Emergency Nursing Initiative (GENI). Representatives of the ACGNN tell the woman’s story at staff orientations and at regional and national conferences. The story is also used in nursing schools throughout Canada. (See http://esthersvoice.com/Pages8-10.pdf)
Nurses are one of the target markets of After the Error which also includes other health care providers and people who have been affected by medical errors. A 2009 study in Healthcare Quarterly reported that approximately one in six Canadians said they had experienced at least one medical error in the past two years. A 2012 report stated that approximately 38,000 to 43,000 deaths occur annually in Canada in connection with health-care delivery.
After the Error has received considerable media coverage. A highlight was Susan’s interview on CBC radio’s The Current. An email we received following the interview stated “I was struck by a line in the book stating a common experience following medical errors is isolation. The book has allowed me to see I am not alone and there are others out there committed to making changes that are so desperately needed.”
The book also received coverage in The National Post, Globe and Mail, Toronto Sun, Okanagan Saturday and The Georgia Straight. A nursing instructor at Red River College in Winnipeg wrote a review for the Winnipeg Free Press. Articles have also appeared in various health-related publications such as Health Action and Update.
We have been invited speakers for events from Montreal to Vancouver Island. A particular highlight was being featured speakers at the national meeting of the Canadian Gerontological Nursing Association held in Richmond. Another highlight was the opportunity to speak at the Risk+H conference in Montreal. In Winnipeg and Calgary several MLAs and prominent individuals in the respective health regions attended our presentations. Susan and I always welcome opportunities to speak about our book.
Our overall goal is to help make health care safer and facilitate discussions on how this can be achieved. Openness about errors at all levels is crucial. Health authorities, administrators, doctors, nurses and other health care staff must work together to help patients who have been harmed and to ensure that the same situation will not be repeated. Meaningful remedies should be developed and personalized to each case. At the same time, compassion and understanding are essential for both those who have made an error and those who have suffered from one.
Through working on the book and from years of experience as a registered nurse I have seen many areas where nurses can make a difference. These range from speaking up in the workplace to becoming politically active. Errors should be reported and areas of risk identified and remedied. Nurses must speak up about their concerns around patient safety at the bedside, in their practice community and in the community at large.
No discussion of patient safety is complete without addressing the question of funding. In this time of financial constraint it is imperative that patient safety not be compromised. A particularly relevant statement was made by an independent advisory group on patient safety in England: “The failures of leadership at M.S. Hospital had to do with attention. Their attention was on their finances – understandable and even appropriate these days. But attention isn’t limitless, and faced with financial and business model pressures unlike any we’ve seen, it’s easy to spend too much of it on the wrong things. All of us need to pay attention, in person, to the work at the front lines. We need to pay attention to our systems for building effective teams to execute work and to improve. And we need to pay attention to creating and maintaining reliable ways to seek, hear, and integrate the voices of our teams and the voices of our patients.”
For information about the book visit www.ecwpress.com/aftertheerror.
ABOUT ROBIN WYNDHAM AND SUSAN MCIVER
Robin Wyndham studied English at the University of British Columbia and nursing at the Vancouver General Hospital School of Nursing. She worked in neonatal intensive care, surgery, psychiatry, and residential care with a special interest in palliative care.
Susan McIver holds a PhD in entomology/microbiology, was a professor at the University of Toronto with appointments to the Faculty of Medicine, and a department chair at the University of Guelph. Subsequently, she served as a community coroner in British Columbia. She is also the author of Medical Nightmares: The Human Face of Errors.
This is really interesting and I'll have to go pick up the book (maybe I can get it on my Kindle!) I always wonder about errors and nursing - certainly we all know people who have made them, or have made one ourselves, and while we gossip about it over lunch, we hardly ever think about what could be done to prevent it. I mean, health authorities tell us to do this or do that after the fact, and we all get scared at what will happen to us or if we'll get into trouble, but I sometimes think it would be better if we as nurses, instead of gossiping could talk through what happened and how we could have prevented it. I wish we spent more time thinking about the repercussions for the patient, and less fussing about whether we'll be suspended or put on probation. Thanks for this. I'm going to read the book!
It's funny, that was my first thought too - I wonder if I can get this on my ereader? It's so rare that anyone talks about medical errors in a research, best practice, improvement light, and not because something has happened and you're visited by the health authority and others. I like the idea of an unprejudiced look at why they happen and what to do after they happen. Smart. I'm going to get this one.
Just to answer the question of the prevsioiu poster, you can find it on amazon here http://www.amazon.ca/After-Error-Speaking-Patient-ebook/dp/B00BAH7XFC/ref=sr_1_1?s=digital-text&ie=UTF8&qid=1382144729&sr=1-1&keywords=after+the+error and on the Sony Store here https://ebookstore.sony.com/ebook/susan-mciver/after-the-error/_/R-400000000000001002541
Book club anyone? This should probably be required reading for nursing students. We really aren't taught much about how to handle yourself when things go terribly wrong. Having watched a colleague suffer through a court case, suspension and the subsequent terrible depression, I think we need to teach young nurses how to handle these situations.
Nice to see the ARNBC blog back! More please - this is great. 🙂
Does ARNBC provide advice or counselling or services or anything for nurses facing this? I'm not or anything, but it seems to me that when it does happen, it would be helpful for people to have someone to call to talk through what is going to happen. Maybe ARNBC should get the authors to be consultants.
I know every situation is different, but I think what that nurse said about realizing she was not alone is very powerful. Except in rare cases, when something happens it's an honest and regrettable mistake. And while our organizations might want to read us the riot act, and the College might punish us, there is something strong in at least having one organization that might not say "we'll support you in your mess" but rather "we still think you're a good person who made a mistake, and we can help you realize you aren't alone".
Nurses who screw up generally feel horrible guilt, and the College and people make it worse. But just to be able to talk to someone and understand that it does happen seems like it would be powerful and empowering. Take away the guilt, think about the problem. Support nurses to change the practice that caused them to mess up. I don't know. I just think what she said is very real.
You are definitely not alone when you make a mistake but people will try very hard to make you feel like you are.
The concept of health professionals being the 'second victim' of medical mistakes is being increasingly recognized. We'd like to draw readers' attention to two programs in the United States. The first is Medically Induced Trauma Support Services (http://www.mitss.org) which provides help to clinicians and family who have been affected by an adverse medical event. The second is a program started by a registered nurse, Sue Scott, at the University of Missouri (http://www.muhealth.org/ForYou). Launched in 2009, the program helps health care workers recover from a traumatic clinical event or an unexpected patient death.