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Three senior leaders at UHN are discussing medical errors they made on the job.
In candid and sometimes painful detail, UHN President and CEO, Dr. Peter Pisters, Chief Medical Officer Dr. Charlie Chan, and Dr. Joy Richards, VP Patient Experience & Chief Health Professions, discuss a moment in their career they will never forget.
The conversations are part of the Caring Safely initiative underway at UHN. It's built on the understanding that a key step on the path to becoming a High Reliability Organization committed to zero preventable harm among patients and in the workplace, is building a just culture free from shame and blame when it comes to mistakes.
In the early 1980s, Dr. Richards was just 18 months into her nursing career when she made a medication error.
"It was a dose of codeine that as I was pouring it, I thought - this isn't right," she says in the video. "But I thought I read the order, I thought I read it right, and so I didn't question it."
It turns out the dosage was 50 times the amount prescribed.
As in all three cases highlighted in the video, Joy's patient was informed of the error and made a full recovery.
All three UHN leaders who spoke out in the video hope to raise awareness about preventable medical harm and reinforce the urgency and need to strive toward having zero incidents.
"As leaders we need to talk about those failures," Dr. Richards says.
In the case of Dr. Chan, it was 1982 when as a young resident he administered the wrong chemotherapy drug to a leukemia patient.
"I could have killed the guy," he says. "It just so turned out in that particular case, it was a minor difference in chemotherapy. But what if the mistake was worse than that?"
Dr. Pisters medical error was to leave a sponge in a patient during surgery more than a decade ago. The error was complicated by the sponge count near the end of the surgery – one showed a sponge was missing but a re-count indicated all were accounted for.
Dr. Pisters points out the mistake was his, but "when errors occur in healthcare, they are rarely the result of one single person, of one single act.
"Safety is something that needs to be integrated into everything we do, all the time, every time," says Dr. Pisters, who launched the patient and workplace safety transformation at UHN soon after becoming President and CEO in 2015. "Caring Safely will never end."