Mark's note: Today's guest post is by Brian Buck, a fellow lean healthcare practitioner who blogged until about two years ago at his site “Improve With Me.”
Recently, I took my son to his primary care provider and the doctor asked if I would like a flu shot for my four year old son. I accepted this and the doctor left the room. A person came in with the shot. I am not sure if they were a nurse or medical assistant since they did not introduce themselves and the office uses both to administer vaccines.
The RN (or MA) handed me the form you fill out that asks standard questions like:
- “Has the patient had reactions in the past to flu shots?”
- “Is the patient currently showing signs of the flu?”
- “Is the patient allergic to eggs?”
- “Has the patient received a flu shot in the last few months?”
While I was filling out the form, the RN (or MA) was prepping the vaccine. The next time I looked up from the form, they already gave my son the shot! She was very quiet and I did not even notice she did this while I was answering the form's questions.
The nurse was lucky my son didn't have “YES” answered anywhere on the form, because there could have been a safety incident. My son has never seen this person in the clinic before, so it is not like she knows us either. I shared with them my concern for the safety of other kids if they administer flu shots before seeing the answers on the form. The RN (or MA) responded she was following the doctor's order.
This incident makes me reflect on how making assumptions blinds us to noticing when we are actually proceeding in the face of uncertainty.
High reliability organizations have a preoccupation with the possibility of failure and they vigilantly search for signs that things are not as expected. We have to have the same preoccupation and humility to consider that our assumptions may be wrong. Once we begin to question our assumptions and biases, we begin to seek expert sources to verify if we are correct.
I tried to connect with the clinic's nursing manager for the next few days but never received a call back. I finally got to talk with them and asked if they have already heard about my concern. She said “No”.
The RN (or MA) had a great opportunity to share with their team about how their risky behavior could have harmed a child. Others could have learned from her and have gained a better understanding of the problem being solved by the form. I wonder if the staff feels safe and protected to share safety stories like this in the clinic.
The manager did say they will talk to the team and ensure everyone understands the protocol. While this will be an OK countermeasure, I hope the clinic leadership will begin building a better safety culture.
About Brian Buck:  He has blogged at  http://improvewithme.com  and can be found on  Twitter  as http://twitter.com/brianbuck. He also had an essay published in Matthew E May's book  The Laws of Subtraction: 6 Simple Rules for Winning in the Age of Excess Everything
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As a medical assistant who has worked in primary care (internal medicine, pediatrics, and family medicine) for 16 plus years, I am appalled. Making assumptions about what has or hasn’t been considered by the physician when they write an order is dangerous. There have been countless times that I’ve caught something that my physician missed before administering a drug, calling in a medication, or relaying lab results to a patient. I’ve always seen a big part of my job to be their back up in this regard for the sake of the patient because physicians are human and make mistakes too. My right to practice as a medical assistant (and a nurse’s license to practice as an LPN or RN) would be at risk if preventable patient harm occurred from something I administered regardless of any physician orders.
You didn’t mention anything about the vaccine information statement. This information sheet is produced by the CDC and it is required by federal law to give the most up to date version to a patient or guardian before a vaccine is given. The intent is that a conversation about the benefits and risks of vaccination will occur before the vaccine is administered which supports informed consent. A consent form should never be used in place of this information sheet and the conversation about it, but unfortunately it often is.
Wow…but this happens so frequently in other (non-potentially-life-threatening) organizations where boxes are checked because they’re told to do so instead of understanding the purpose behind them. I hope this clinic and its leaders learn to generate genuine engagement and proper use of their processes.