Fix

Nearly 30 years ago, I had no idea about patient safety as a junior medical intern, much less keep my patients safe. 

The vivid real-life stories from Amy Edmondson's Right Kind of Wrong reminded me of the internship experience. She mentioned the near-fatal mistake of complex failure in a ten-year-old boy, whose face turned blue after surgery. The boy was given a morphine overdose – several times more than was appropriate. 

Alas, that story was exactly what I had encountered in a surgical unit where a domestic maid was found unarousable after an appendicitis operation. Within minutes of being paged by the nurse, I rushed to check on the patient and found a near-empty bag of morphine. I ordered a dose of antidote, which worked like true love's kiss for Aurora. That fixed the problem and my patient woke up. End of the story. 

Except that it's not.

Looking back, I was so naive to take a quick fix without reporting the incident. I dared not speak up. And that's it. 

As a matter of fact, we tend to take short cut in the working environment, even for simple process failure like running out of clean linens. The so-called "first-order problem-solving", as you can imagine, is simply walking to another unit and taking linens from their supply. Problem solved. Minimal time and effort.

It is time for me to quit the first-order problem-solving habit. We better think about what Amy Edmondson dubbed "second-order problem-solving." That could simply mean reporting the shortage of linens and taking the initiative to work around the linen ordering system.