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Degrees of Reasonableness and Understanding Complexity

Colin Campbell
by Colin Campbell on 06/06/18 18:00

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Recently in the practice we had an inadvertent data breach where we sent a credit card receipt slip for a transaction that had been carried out to the wrong person.

One of the most heinous crimes in all of history I reckon?

The individual who received this through the post contacted the practice and asked us to carry out a full investigation into what had happened, which of course we did on that request and reported back.

It turned out it was human error.

The only way we will stop human error, of course, is to stop being human and we may find that difficult.

I reflected on this for a while in the practice and the upset that it caused to the team overall and I thought “if I had received that I would have simply sent it back to the practice and said I think there has been a mistake” and that would have been the end of the matter; but some people feel the need to push things to the nth degree and to cause as much description and distress as possible. I don’t quite understand that.

I am quite happy to accept the fact that sometimes patients forget to come for appointments, or sometimes they get caught in traffic because I want them to accept the fact that sometimes I am late too or inadvertently send the wrong credit card slip out.

I can promise that that doesn’t happen very often (it’s the first time I have ever known it to happen and I bet it will be the last) but it will not be the last human error event that happens in our business.

We’re terrified in healthcare now that should we forget to enter a set of notes, or even anything in a set of notes that we’re liable to be hung out to dry because the fear of the wrath of a regulator who has lost its legitimacy of authority still hangs over us in the air.

So, let’s imagine for a minute that I am asked to send some clinical material to my regulator and I send the wrong notes.

I send the notes for the wrong patient.

What do you think would happen?

I would like to think that the regulator would get back to me and say “don’t worry Mr Campbell you’ve inadvertently sent us the wrong notes due to human error, we understand that that was a mistake, please just send us the correct notes”.

Unfortunately though, in the climate that we still live, I don’t believe that would be the case.

It’s why I am interested though in the fact that I received an email communication from the GDC last week regarding a case that I am involved in in which they referenced the wrong Registrant.

In the first line of the email they referenced the correct Registrant and in the second line they referenced another (one that I don’t know and who is not involved in this case).

Some point after that the email was ‘recalled’ which of cause is nonsense because I still have the email and when I pointed it out I was told it was a ‘typo’.

A typo is misspelling, not a cut and paste error where someone’s wrong name is left in place.

What should I do about this?

I could react as the patient reacted in our practice and ask for a full investigation and for the outcome of that investigation to be sent to me due to a breach of data protection, but that would be to spend everyone else’s registration fees on another investigation.

I would rather not do that and hope that in some very small way my action of restraint will lead to a wider culture of restraint where people understand that the complexity of the world that we live in leads to errors by humans and all we can do is try to learn to reduce those as much as possible.

Good luck with that ay?

 

Blog post number: 1665

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Colin Campbell
Written by Colin Campbell
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