Dr. Runjan Chetty recalls it as an error of distraction.
It was a number of years ago, before Dr. Chetty became Interim Medical Director of the Laboratory Medicine Program at UHN. He was known for an open door policy in his office, so several colleagues came in seeking his input on a lab initiative as Dr. Chetty was reviewing a patient's pathology case.
"While we all think we can multi-task, we're really not very good at it," Dr. Chetty says now. "We can manage our time to do multiple things throughout a day, but doing even two things simultaneously leaves us unnecessarily susceptible to errors."
That day, the conversation in his office eventually required some mediation. Dr. Chetty weighed in and offered his opinion while finishing up the pathology report, sending the results to the patient's treating physician.
Problem was, he left out the most important part of the report – the diagnosis.
And it wasn't until several weeks later that Dr. Chetty realized his error.
Realizing his mistake
The "cliff-hanger" report revealed itself when a new case came in from the same patient. It was a different biopsy sample this time, and when Dr. Chetty looked at the patient's previous pathology report, signed out by him, he saw the abrupt conclusion – he left out the diagnosis.
"It was an awful feeling," he says. "Realizing you made a mistake that causes worry and uncertainty for a patient and their family is difficult to accept as a healthcare provider."
Fortunately the second biopsy was needed regardless to monitor patient response, but Dr. Chetty says it could have ended much differently – potentially causing an at-risk patient to go through a needless biopsy.
Now, Dr. Chetty has a personal policy where he closes his door whenever a patient case is being reviewed, effectively blocking out all possible distractions. It's not the open door policy he'd like to be projecting, but with safety on the line LMP staff don't seem to mind knocking.
Caring Safely in UHN labs
Creating a just culture where mistakes are free from shame and blame is a key component of the Caring Safely initiative underway at UHN. And though Dr. Chetty has spoken out about his "error of distraction" to colleagues before, there is now an added emphasis on safety vigilance – especially for areas already facing significant quality and safety regulation.
Three months ago, LMP underwent one of its most extensive external quality and safety reviews, where staff successfully demonstrated safety practices that complied with hundreds of standards mandated by the province.
But, its safety accomplishments such as this that have Dr. Chetty cautioning staff to not let the structure of their environment lead to complacency.
"As a clinical laboratory we are tightly regulated through various accreditation bodies, but there will always be potential for error," says Dr. Chetty. "Safety should be on the forefront of everybody's mind and we need to encourage open discussion across all areas of the lab to actively prevent errors."