So we don’t always get everything right….

Over the weekend I took a break from studying and went to the cinema to see the Alan Bennett film “Allelujah!”. Based on the trailer I was expecting to see a comedy with a star-studded line up, what I saw was unexpectedly different. While not wishing to give any spoilers, the film turned out to be powerful, uplifting and a reminder that we don’t always get things right. The film chimed close to home for me...

The research that I am undertaking is seeking patterns and reason within the cacophony of errors, mistakes, misjudgments, and accidents that, all too often, results in the patients under our care coming to harm. I spend my days trying to understand whether poor ventilation causes more harm than shiny floors and trying to understand when the error was made - what caused the floor to become shiny or for the ventilation to stop working.

While working to understand the impact of the error, it is clear that no one sets out to cause harm intentionally. Decisions are made in the moment and with often multiple factors that govern the decision. Without the aid if crystal ball it is not possible to understand the full magnitude of the implications.

A good example is when the decision to fit window restrictors to all hospital windows was made, did we truly understand the impact that it would have on airflow and the subsequent impact of hospital acquired infections during a pandemic? The decision was made in all good faith to resolve a serious health concern, but its impact could be as severe as the problem it was trying to solve.

When reviewing thousands of harm incidents, it is important to stop and think not about the person that caused the error, but the context in which the error happened, and the system pressures that may have added to the error occurring.

…so even if this type film is not your cup of tea, I urge you to go for just the last three minutes. No spoilers, just go and see.