Read the case study “An Insulin Overdose”
Discussion Questions :
1) In this case, insulin was routinely distributed from the OR pharmacy in high concentrations, thereby posing a great danger if administered incorrectly. Can you think of an example in your own work environment where you thought to yourself, “This is a disaster waiting to happen!”
Now that you have identified examples from your work environment, take a closer look at the suboptimal systems that may be at work. Why does this “disaster waiting to happen” exist in your workplace? Is it because there is no reporting system for such situations? Do the employees feel disempowered to change their workplace? There are many possibilities.
Next, what are some ways in which those systems could be improved?
2) Let us assume that the resident caught her mistake before she injected the syringe with insulin, so that no harm was done. We may think of such a scenario as a “near miss” event. In many work environments “near misses” are greatly underreported, and the opportunity to learn from them gets lost. If you are a clinician, can you think of a “near miss” experience of your own? How did you change your practice as a result?
3) Mistakes and adverse events often trigger the “who” rather than the “how” question, thereby fostering a blaming environment in which reporting mistakes and near misses does not feel safe. Think of a mistake or near miss that you observed at work. How was it handled? Did the organization’s response to the error make you more or less likely to report your own mistakes? If your answer was “less likely,” what could the organization have done differently to make you more likely to report your mistakes?