JOIN OUR MAILING LIST

By signing up to our mailing list you will receive information about products and services. We will do our best to send you only communications that we deem to be relevant to you and you can change your mind at any time.

View our privacy policy for details on use and storage of your personal data.

GENERAL

T  +61 3 9857 8277
admin@safetywise.com

INVESTIGATION ASSISTANCE
(After Hours)

M  +61 (0)499 333 769

Office & Postal Address

Suite 2, Level 1,

860 Doncaster Road,

Doncaster East, VIC 3109


MISSED OPPORTUNITIES - INVESTIGATING AND LEARNING FROM POSITIVE OUTCOMES

September 5, 2017

 

 

THE “BAD PARENT” MOMENT…

Have you ever had one of those “really bad parent” moments that make you question yourself? Well last week, I had a doozy which I’m sharing – not so you can judge me (please, no haters…) but to highlight a really positive experience from a bad event.

 

My eldest son, James, complained of a terrible stomach ache on Thursday. What did I do? Well, I told him to take it easy and I was sure it would improve. By Thursday night, he was moaning and telling me it was really bad. What did I do? Well, I sent him to bed with a heat pack for his belly, told him to calm down and get some sleep and assured him he’d feel better in the morning. At 4:00am on Friday morning he stumbled into my bedroom, crying how bad it hurt. What did I do? Well I looked at the clock, saw how early it was and told him we’d go to the doctor when they opened, that it was way too early to be awake and he should go back to sleep.

 

When the sun finally came up on that Friday morning, I was busy organising the other children and getting them off to school. I rang the GP and very luckily secured an appointment for James at 9:45am (miracle !) so a doctor saw James early that day. After some prodding and poking, the doctor said she couldn’t really detect anything super serious but given his history (twisted bowel and major surgery as a baby), she ordered some tests to be sure.

 

So I took James home, put on a video for him, gave him a blanket and pillow and proceeded to spend most of the day on a teleconference and doing office work. At 2.00pm, the kid’s school rang to tell me my other son, Jacob, was unwell and asked me to pick him up. So I raced off to do that and was walking him into the house – juggling a puking child, a vomit bowl and a huge school backpack when the phone rang.  Wonderful timing, I thought. I asked James to get the phone and was tending to Jacob when James appeared and told me “they said it’s urgent, you have to talk to them”.

 

On the phone was the GP who had looked at some of James’s test results and told me it was critical that James was taken to the hospital immediately. She had phoned ahead and apparently people would be waiting for us. Forgive my language, but I will admit I had that little “WTF” moment at that point. I had my youngest son vomiting, I looked at the clock and knew I was due to go and collect my daughter from kindergarten and now was being told my eldest son had to be at the hospital immediately. Some quick telephone calls and frantic juggling followed, before I was in the car with James on the way to hospital.

 

GOOD WITH THE BAD

What followed was a frantic, nerve wrecking time. The doctors were very worried because apparently the scar tissue and adhesions from the surgery James had as a youngster had twisted and were cutting off the blood supply to some organs. So, quite a bit more serious than just a belly-ache (and yes, in answer to your logical question I did feel tremendous guilt I had simply “brushed him off”). Now the reason I wrote about this, is I felt I had to highlight the tremendous amounts of positives we experienced in the face of such a worrying time.

 

Usually when I hear about visits to emergency departments and hospitals, all I hear about is people’s negative experiences. They complain about the waiting time, the food, the rush, the medico-lingo, not being told what’s going on etc. Well I have to say that despite the negative experience of being there with a medical emergency in the first place, I could not have been more impressed with everything that happened once we walked through the doors.

 

POSITIVES

  • Classification System: When I walked into the hospital with James, the first thing I noted was about 10 babies / toddlers in the waiting room. Internally I groaned, thinking that the little ones would take precedence above James and we’d be waiting for hours. But the hospital follow the 5-point National Triage Scale (1 - Immediate Resuscitation, 2 - Emergency, 3 - Urgent, 4 - Semi-urgent, 5 - Non-urgent) to help them identify critically ill patients and treat them ahead of patients with less serious problems. The Triage Nurse immediately assessed James as 2 - Emergency, so we didn’t even have to wait one minute in the reception area before being escorted through to the Paediatrics Emergency Fast Track area.

  • Environment: Can you imagine being a kid and having a whole bunch of doctors, nurses, machines and instruments surrounding you? Well, I have to commend the hospital. The paediatrics area had murals on the walls, kids television shows on screens and overall the rooms were designed for kids, not a sterile looking, hospital environment. It certainly made the area less formidable and the children more relaxed and comfortable .

  • Remembering the “Clients” - The hospital personnel were always conscious that they were dealing with kids, not adults. Every single person who came to see James took the time to explain who they were and why they were doing what they were doing. They knew when to be comforting, when to cajole, when to be firm, when to take time and when to make deals. Every single Nurse, Doctor, Wardsman, Radiologist, Ultrasound Technician, Anaesthetist etc. were outstanding in their attempts to make the experience a little less frightening for James.

  • Establish a personal connection and talking TO people: As soon as we registered at the front desk, the personnel assessed James and started addressing him and asking him questions. This continued all the way through to the nurses, doctors etc. They didn’t just treat James as a kid and talk to me as a parent, but took the time to try and establish a good working relationship with him which I thought was wonderful and I know James really appreciated that everyone was treating him with respect.

  • Understanding and Communication: The communication was fantastic. In the heat of the moment, various doctors were racing in, examining James and talking to each in medical “lingo” but each time, they would say to the nurses “could you explain that to Mum in English when we leave?” The nurses took the time to break things down into everyday language for me which took away some of the fear of the unknown as I heard all the technical terms.

  • Checking and Double Checking: Every time medicine was administered, the double checking occurred to verify the patient was James and the medication, as well as the dosage etc. was correct. Without fail, this was a rigorous routine. 

  • Review Process: Another positive was in the review process. At one stage, a Doctor was looking at all the test results and said he thought he knew what was happening, but he said he would feel more comfortable in seeking another opinion. There was no ego driven early conclusions reached and all the Doctors were happy to discuss various alternatives with each other to reach the best option.

  • Stop Moment: When the moment came that James was assessed as needing urgent surgical intervention, there was a flurry of activity.  Wardsmen came running, his bed was raced up to the Operating Theatres and it seemed like Nurses and Doctors were everywhere. In the Operating Room, Nurses were scrambling to attach monitoring devices and attempting to insert more cannula’s for fluid and medication. 

  • With the frantic activity, James started to panic and decided at that moment that a better option would be to flee the OR. The Anaesthetist, bless him, recognised that everything was moving all too fast and frantic for James and simply yelled out “Stop!”. Everyone looked at him and he gently reassured James and quietly told the Nurses that he was going to give James some nitrous oxide to calm and relax him and to hold off inserting the cannula’s and attaching the ECG leads, pulse oximeter probe and blood pressure cuff. This resulted in a one minute delay in being able to administer the general anaesthetic, but made all the difference to a terrified child, who relaxed (and happily co-operated once he became a bit delirious on the nitrous oxide).

  • Commitment: By the time the surgery was over and James had spent time in recovery it was about 9:00pm when he was transferred to the Paediatric Ward. Once he was settled in, I have to admit I was astonished to see the Professor of Paediatric Surgery at 10:30pm, who had stayed late to check that the surgery was successful and James was in a stable condition. To a worried parent, I couldn’t have appreciated this dedication and reassurance more.

  • Paediatric Wards: To keep me busy while I was waiting for the surgery to be over, I was reading every pamphlet and poster I saw. A statement I read about paediatric care was that the hospital advocates that all care is “planned with and directed toward the child and family”. I can honestly state that in our experiences, we saw that this goal was not just written words on paper,  but definitely put into practice.

  • The wards were designed for children and totally accommodating for parents. Each child’s room had a comfortable day bed actually built in to the room for parents, rather than a lumpy old chair or fold out bed for a parent to stay the night. The nursing staff provided support not only to the children, but were constantly checking on the parents as well. There was a really nice kitchen facility for parents and even a super cool games room for the children who were well enough to get out of bed.  

  • Shift Change-Overs: I was very impressed with the shift hand-overs. The Nursing staff came to each room for every hand-over and all on-coming staff were briefed on each patient, so even if they weren’t specifically designated to take care of that patient they were aware of the situation of every patient on that ward. The handovers weren’t superficial either. They were quite comprehensive and the on-coming staff asked questions, clarified issues and took notes.

  • Discharge: James will be an out-patient for a while and having regular reviews. On discharge from hospital, we didn’t leave bewildered.  I was very impressed that medical personnel took the time to really explain what had happened, they gave me a copy of all the notes, they explained all the medical terminology and clarified written instructions for post-operative care.

 

THE VALUE OF ACKNOWLEDGING AND LEARNING FROM THE POSITIVES

So, all up, despite the harrowing experience I have to say that I saw systems and processes which were applied in a very positive way and had a good outcome. While he’s still very sore and will take a while to recover, James is a very lucky kid (and says he has forgiven his mother for my “bad mother moment”). Another side benefit from being physically okay, is that the whole experience for James was not as psychologically / emotionally traumatic as it could well have been, thanks to the wonderful people who took the time to think about their patients being kids.

 

When I finally had time to relax and reflect on everything that had happened, I made a note to myself to ensure I submitted some positive feedback back to the hospital. I think as a society, we’re very quick to criticise and whinge about things, but when things go well I think fewer people take the time to actually give the feedback or mention the good to others. 

 

But apart from acknowledging the positives, from a systems perspective I believe this tale is reflective of how the positives can teach us.  I think we fail to recognise that by looking at the things that went right in any system, it can actually help us in addressing the things that went wrong. From an organisational perspective, I think we focus so much on the negative. When we have an incident there is an in-depth investigation to identify why it went wrong. But when’s the last time you saw a totally proactive investigation take place to identify why something is going right? I believe we can definitely learn by taking note of things going well and identify those factors that are making the system safer, then apply the principles to many other aspects of our business. Stay tuned for an example of this in an upcoming article...

 

Interested in Knowing More?

Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/

 

Additional ICAM Related Services

Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:

  • Quality review of incident investigations using ICAM

  • Trend analysis of organisational factors contributing to serious incidents

  • Participation in investigations as an external / independent party

 

 ABOUT THE AUTHOR- Jo De Landre (Chief Operations Officer)

After 15 years with the Bureau of Air Safety Investigation (BASI),which became part of the multi-modal Australian Transport Safety Bureau (ATSB), Jo started co-facilitating ICAM training with Safety Wise in 2001 as the Principal Human Factors Consultant.

 

In 2005, Jo was promoted to the position of Executive General Manager of Safety Wise and beyond providing human factors specialist services and ICAM training and Investigations, she is now involved in strategic activities such as project management and developing safety management programs.

 

Jo has been the Safety Wise Lead Investigator for many high profile accidents, including multiple fatality investigations. She has a Bachelor’s Degree in Applied Psychology and a Graduate Diploma of Psychology, and has published papers in aviation, mining and police journals and publications.

 

Joanne has also been Secretary of the Australian Aviation Psychology Association (AAvPA) for close to a decade.

 

 

 

 

 

 

Please reload

Please reload

Recent Posts
Archive
Please reload

Search By Tags