Hi. I'm Victoria and I'm a specialist palliative care physician with an interest in medicines management at the end of life. I made a pledge last year as part of NHS Change Day to constructively criticise and report any drug errors that I came across in my practice.
Errors are inherent to clinical practice, usually as a result of systems and processes rather than people acting recklessly or being negligent. For example, I once had a case where the prescription wasn't clearly written and information was missing. I took the chart to the junior doctor who had written the prescription and said "can you talk me through this?" It turned out that she wasn't sure what the dose interval was, so left it blank and was about to look it up when she'd been called somewhere else. Error easily rectified and lesson learned: interruptions cause mistakes.
How can we make our care safer if we don't report these errors and learn from them? No-one would deny errors are stressful events, and not just for patients, but we owe it to ourselves and the people we care for to do everything we can to stop them happening again.
My pledge was to have the courage to challenge constructively and in a supportive manner, unsafe prescribing practice.
My first challenge was to present a talk to 200 local GPs about opioid prescribing at end of life. I told them about the never events list, which is where an incident report will automatically follow if an opioid naive patient is prescribed too much opioid. I explained why we did this, discussing the importance of understanding the system as much as human error. We try to be supportive to the prescribers as well as emphasising patient care.
I was then asked to lead some smaller group workshop events around the safer management of opioids at the end of life. Having become a certified Change Agent through the School for Health and Care Radicals, I decided to change my strategy with the GPs this time. Instead of standing up and making a speech, I tried a more transformational approach, encouraging the participants to think about their practice and the processes that support (or don’t support) the safety of their patients. We even made a “pledge wall” of individual commitments to change and – to my delight and surprise – everyone contributed.
I'm hoping the reporting culture will start to change. Instead of being afraid, let's try to understand what's happening and what we can do better, in connection with each other.
For me, I realised that I couldn't criticise others unless I was prepared to be open to criticism myself. After all, change starts with me. Making my original pledge and participating in the School for Health and Care Radicals has made me look at my own practice, to challenge circumstances where perhaps I could have done a bit better, maybe done more for my patients or helped the people that I work with. It’s not easy to hold the mirror up to yourself and be honest. But it's been really powerful for both my professional and personal growth. It’s made me realise is that this is what I want to do in my life: to help other people to learn and to grow. There’s so much work to be done to achieve the best possible end of life care for everyone. For that reason I've decided to change from being a palliative care physician who does some teaching to an inspirational educator firmly rooted in clinical practice.
So, my action for next year is going to be to help at least one other person to open their hearts and minds, to truly believe, that change starts with me.