IDEAS
healthcare-human-factors-blue-divider

My Patient Safety Epiphany

OCTOBER 12, 2016 • BY ANJUM CHAGPAR

In my over 20 years in healthcare, I’ve worked on more projects than I can count, all with the common goal of making things better. Better sometimes means easier, faster, or more enjoyable. And often it means safer. Because the reality is that healthcare is inherently unsafe. And it’s scary.

healthcare-human-factors-blue-divider

Share on

healthcare-human-factors-blue-divider

Imagine having a preterm baby. Your pregnancy is cut unexpectedly short, your tiny, translucent baby, not yet able to breathe or eat on his own, is now in a noisy, cold, bright, Neonatal Intensive Care Unit (NICU), when he should still be warm and wet inside of you. This alone is terrifying. But now, imagine that the NICU, which routinely administers medications and nutrition to these preterm babies via syringes, uses empty syringes that look almost indistinguishable from syringes coated with Heparin. Heparinized syringes are used to minimize blood coagulation when drawing blood for blood tests. But if they are accidently used to administer fluid to a baby, the results could be life threatening.

On August 12 2014, I was 28 weeks pregnant and experiencing what I thought was normal pregnancy back pain. It was actually labour. When I walked in the emergency department to get checked out, I was told that I was fully dilated and that my baby was breached and moving down the birth canal. I was wheeled into the OR and a few minutes later, I gave birth to a two-pound baby boy via C-section.

We stayed in the NICU for the next 87 days. During the first month, my son needed to be resuscitated between 20 and 40 times a day. Too tiny to nurse, he was fed via syringes and received multiple medication injections each day.  In total, he received almost 2000 injections during his stay. Each one of these was an opportunity to inadvertently deliver heparin through a look-alike syringe.
But because Healthcare Human Factors had worked on a project a few years before in the very same NICU my son was now a patient in, this wasn’t the case. Through our assessment of the human factors risks associated with the look-alike heparinized syringes, we convinced the hospital’s leadership to break their procurement contract with the syringe manufacturer and remove them from the NICU.

Working in patient safety is one thing, experiencing patient safety is quite another. The fact that in healthcare, we continually place our most vulnerable in situations where they may be further harmed, is intolerable. I now know this viscerally. While we, my son and I, were lucky, the fact that there are many others that are not as privileged, is not lost on me.  As a mother of a patient, I feel a renewed sense of calling to our work. Our progress is slower than I would like, and there is so much to be done.  And like many things in life, I know we can do better, if we all work on this together.

long-blue-bar-365px

Working in patient safety is one thing, experiencing patient safety is quite another.

Anjum Chagpar, Managing Director

healthcare-human-factors-blue-divider

Share on