If you have worked in an office any time in the last few decades you will likely have seen a sign near someone’s desk that says:
You don’t have to be mad to work here, but it helps.
Next to that may be another little card with a story about four people called Everybody, Somebody, Anybody and Nobody.
There was an important task to do and …
Everybody should have done it, Anybody could have done it, Nobody did it. Everybody thought Anybody could do it but Nobody realised that Everybody wouldn’t do it so.
Everybody blamed Somebody when Nobody did what Anybody could have done.
This truth may be irritating in the context of office politics and marketing plans, but in the context of patient care it is highly dangerous.
Let’s take a common example: the safe use of gentamicin, an intravenous antibiotic
For physiological reasons, different patients’ metabolism of gentamicin can be wildly different. What’s more, the ‘therapeutic window’ of gentamicin is small which means there is not much difference between too little (which won’t kill the bugs) and too much (causing irreversible deafness, kidney failure or worse).
So, to prevent harm to patients receiving gentamicin (and similar aminoglycoside drugs), a blood sample needs to be taken 8-12 hours after the first dose to check ‘gent levels’.
And who is responsible for taking the necessary blood sample? The answer depends on the setting but is usually a junior nurse or junior doctor — the members of staff most fraught with too many patients and cognitive overload. The staff, in other words, who are most likely to forget or be caught-up with more urgent tasks.
The result is that poor management of gentamicin levels, even in advanced treatment settings, is horribly common.
How do we get Somebody to take the blood at the right time – and act on it.
To answer that, let us look at the nature of accountability and responsibility:
Accountability: senior clinicians, service managers, CEOs are all accountable for the care of patients in their remit. They need to make sure that the actions that Everybody needs to do are indeed done.
Responsibility: ward clerks, clinic nurses, junior doctors may all be responsible for the individual actions that Somebody needs to do.
Is poor management of gentamicin levels a failure of accountability or of responsibility? The answer is, both. If Somebody forgets to take the blood then they have failed in their responsibilities. That is clear.
What is less clear is that those accountable have also failed. Accountable leaders are the ones who should set-up and monitor the systems that ensure responsibilities are carried out effectively and without error.
System design is a much more difficult task. Assuring that someone attends to a detailed task is complex. The sad truth is that, in healthcare, this is most commonly done by word-of-mouth, handover sheets, and the sheer effort of remembering on the part of junior staff.
It is here that the main EPR (Electronic Patient Record) or HIS (Health Information System) vendors are failing our clinical staff and our patients. Such systems do not provide the all-important link between task, patient and staff member. Tasks are usually recorded against a patient, but are not then assigned to a responsible individual.
In other words the EPR tasks Anybody rather than Somebody.
This means that staff don’t have a way to easily handover their own tasks to peers during transfers of care or changes of shift.
CAREFUL is designed specifically to make up for this by integrating with the EPR to manage task-level activity against both the patient and the user. It also provides the essential mechanisms for task handover between individuals and teams during transitions of care.
Relying on the memory capacity of overworked doctors and nurses is a poor substitute for adequate systems. It is demonstrably dangerous.
Until we have adequate task management and handover systems, it remains the case that:
you don’t have to be a memory genius to work here, but it helps.
