Every doctor’s ‘nightmare’
MD leads effort to help colleagues deal with mistakes and traumatic times
It took years for anesthesiologist Dr. Malone Chaya to come to terms with the time he almost killed a patient by accident.
Now, he’s spearheading an effort within the Saskatoon Health Region to help other health care providers through mistakes and traumatic experiences.
Fifteen years ago, when Chaya was still working in South Africa, he was looking after a dental patient. The patient was unconscious when Chaya drew up a syringe with a local anesthetic and set in on his cart.
While he shifted his attention to something else, he asked his assistant to mix an antibiotic. Unknown to him, the assistant used that syringe.
The local anesthetic is potentially lethal — the odds of death are greater than 50 per cent if it’s injected into the bloodstream.
Chaya started administering the antibiotic, and as he looked around for the anesthetic, he froze.
“It’s kind of, ‘Oh my God, what has just happened?’ ” he recalled.
He was trained in measures to counteract the medication, and the patient didn’t suffer any harm — but he still lived with the incident, he said.
“You don’t sleep. You have this recurring nightmare. The last thing you want to do is harm a patient.”
He came to terms with it as he began to learn he wasn’t the only doctor who had ever made a mistake, he said. He now talks with colleagues involved in similar incidents, telling them how they are going to feel and helping them make changes so their next patient gets better care.
About two years ago, when the health region embarked on a 90day focus on safety, Chaya came across the idea of Schwartz Rounds. Developed at the Schwartz Center for Compassionate Health Care in Boston, Schwartz Rounds are held in hundreds of organizations throughout the U.S., Canada, the U.K, Australia and New Zealand.
The idea is to provide “regularly scheduled time during their fastpaced work lives to openly and honestly discuss the social and emotional issues they face in caring for patients and families,” according to the centre.
More than 100 people attended when SHR held its first session on April 10, according to the health region. Many talked about experiences that happened 20 to 25 years ago that they’d never had the opportunity to talk about before; the rounds let people keep the human dimension to health care when faced with trauma or an error, Chaya said.
“As human beings, we will make errors, and we cannot pretend that when we care for patients it doesn’t have an impact on us.”
He hopes the rounds will continue every two months for the next two years, thanks to funding from the Royal University Hospital Foundation.