Thursday, 31 January 2008

Is this the world we live in-2

You wouldn't believe this. But after reading the annual stella awards, and if you can accept that this the world we live in, then what i encounter today is an additional episode to those awards, only in a smaller scale.
I am one of the writer, as part of my job, to write on "medicine management newsletter" every quarter. I write about latest shares on drug company that you should either sell, hold, or buy. Just kidding. No, i don't write those, although i wish i do. I write about patient safety, the side effects of the latest evidence on some drugs, reminder for the prescribers on the evidence or absence of evidence for the use of some new drugs.
On the topic of patient safety, of course, inevitably, as human beings, we do make mistakes. Some are near misses, which has been realized before it gets to the patient. Of course, knowing the inevitable, we should endeavour to learn from our mistakes and share our learning. That is the NHS culture that we are in, not name and shame but learn from mistakes , and make the neccessary changes so it doesn't not occur again. That is the world we live in.
However, what happened today definitely doesn't quite fit in my notion of the world i am living in. We wrote in our newsletter that someone ( note, i used the word someone) wrote "International units" for insulin,the "i"  which was misread by (someone) as 1, so 41 unit was administered instead of 4 units. So we just wrote it in our newsletter to alert everyone not to make the same mistakes, and write units instead of IU for insulin. In actual fact, we did write (a type of healthcare professional not someone), which apparently got us into trouble. The specific healthcare professionals rang my manager and had a go at him, telling him how upset she was to see us writing "misread by ....... and administered 41 units". My manager, being very nice and patience apologised to her and said this will be a learning for him to be cautious bla bla bla
He then came round to me and told me the story. He didn't blame me or anything. I plainly stated the fact that i am upset too, that she is upset about my masterpiece.  I think that is over reacting. Plus i didn't name anyone. Why is she upset about us? We are not the ones who made the mistake or naming and shaming. There was no names written, just a ........., just like you saying a man, or an engineer or an architect. Is that naming and shaming? Plus, it's the patient that is our utmost concern. We are here for the patients, not about our egos and pointing fingers here.
Come on... what's wrong with this world? Where is the virtue of owning your mistakes, confessing it and learn from it. What happen to "you are responsible for your own action and decision? "
Our world is indeed an "adam world" . In the bible, adam blamed the woman that God gave her for eating the forbidden fruit( not the double blame here, the woman and God who gave him the woman). Everyday, i am seeing this being replayed again and again.
I learn from it too, now when i write on newsletter, i will put it in passive tense and say something like it was misread as .. instead of misread by.... or it was written as.. instead of written by.... (ghost? )
anyway, that was my interesting chapter of my life manual here. It occurs to me that everyday is an unique experience and i am here writing every page of my life.
Indeed, everyday i am still asking myself : "is this the world we live in? "

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