Pre Arrival Post – Why I am Attending

While my career in the medical field has not been very long, I have still been directly involved with many patient safety errors. When these have occurred the focus immediately shifted to the individuals that contributed to or made the error. While some outcomes have stimulated professional and productive conversations, others have resulted in blame and shame. The conversation rarely focuses on the role of the larger system. As I was previously taught, every system is perfectly designed to get the result it gets. Instead, the focus should immediately pivot to evaluate the system and how systems can be improved to catch inevitable human errors. I think of the many patients that have been harmed and died which might have been prevented.


The first patient that sticks out in my mind was from my first few months in the medical field as an emergency room technician. Instead of a TPA infusion rate of 1mg/min, it was 1mg/hour and the patient with an acute stroke missed the therapeutic benefit they should have received. While easy to blame the pharmacist that printed the medication label, this would be a naïve conclusion to the safety error. A plan to prevent reoccurrence needs to focus much more broadly, focusing on an electronic medical record that prevents this mistake. In addition, communication and an open mindset needed to be improved in this emergency room. Shortly out of college with only a basic EMT training, a rate of 1mg/hour for 60mg seemed far too slow for an acute stroke. When I tried to raise the warning up my chain of command, my nurse immediately shot me down stating of course the medication was correct. Only many hours later, too late to save the patient’s brain tissue, the error was discovered by another unit and another nurse. Instead of having a debrief session or turning the error into a team building opportunity, team members became defensive and attempted to blame others. While too junior to change the culture after that event 8 years ago, I am now in a stronger position to enact change as I start a new job.


This was just one of the patient safety events I have been a part of. Others include a patient handoff error and chart confusion leading to a double dosing of insulin and severe hypoglycemia. Another involved missed hypertensive emergency and intracranial bleeding leading to my patient’s death. Despite my best efforts after these events, I do not feel our system has significantly changed to prevent them from occurring again. I hope this week can help me change my community and reduce patient harm.