Saturday, 4 September 2010

Making mistakes

Shelf of reference books
I finished and handed in my case study last week, and did a bit of work on the presentation about it that I have to give next week. A bonus was that I discovered an element of best practice that wasn't being observed in this hospital, so I can put that in as a recommendation, concerning water-soluble vitamins (B and C) being given to patients on haemodialysis.

I was intercepted by an Infection Prevention nurse on one of the wards last week, and invited to do a handwashing test. She smeared some gunk containing 'germs' that could be seen under UV light, and then I had to wash it all off and check with UV afterwards. I did quite well, but missed a patch on my wrist. It was an interesting exercise.

I've already mentioned that the mistakes that I make are picked up and recorded and I am given feedback at the time, and at my next review, and no doubt for eternity. While I have been with the qualified dietitians, they have made similar mistakes, and it is mildly annoying that I have to keep quiet.

For example, in the High Dependency Unit (one step down from Intensive Care) I was shadowing another dietitian when we discovered that the wrong feed was being used. In this particular case this was quite a serious error because the patient was at risk of refeeding syndrome and her blood electrolytes were a bit out, but the dietitian made a bit of a fuss in front of the patient who then looked worried, so I said something reassuring. If that had been me, it would have been put on my record and I would never hear the end of it.

The same dietitian also mentioned in the office, when talking to someone else, a howler she had made when looking through medical notes on the ward. She noticed that someone had written that a patient should be given 'soft fluids' (this may be a confusion of 'soft diet' and 'thickened fluids'), and had said something like "What does that mean?" Turns out, the person who wrote it was standing within earshot. This is exactly the mistake that I made earlier in my placement.

On the other hand, I am still making mistakes too, even if they aren't observed. While I was out on a ward on my own I was talking to a tube-fed patient who had undergone quite a major head and neck reconstruction following excision of a tumour. He wasn't able to speak, but wrote on his notepad that he was looking forward to a cuppa. I mentioned that his medical notes stated he might be able to start trying to swallow again soon, but he hadn't been told this by the medical team.

When the tea trolley came round, luckily I was still hanging around the ward and he came over to ask whether he could have a drink. I had to say no, and that I probably shouldn't have mentioned it because it's the doctors who make that sort of decision. It would have been positively dangerous if he'd tried to have a drink, given that he'd just had surgery to his tongue and oesophagus - it might have gone into his lungs, which is potentially fatal. I have learned just as much from this error while I was on my own as I would if someone had been watching me.

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