Learning from mistakes

Susan Willatt argues that everyone can make mistakes but the important thing is to learn from them.

No one is perfect. Mistakes can arise in our private life; they can also happen at work. If a plumber put a nail through a pipe, it would cause a mess, but it is most unlikely that anyone be harmed. However, if a dentist makes a mistake, a patient could well be harmed; a small risk but a real one. So think again: 'Have you made a mistake recently?'

So why do we make these errors?

Dr James Reason is a renowned cognitive psychologist and an expert on error. He began to explore human error after he put cat food in his teapot, while making tea and feeding his cat. The two components got mixed up; both the teapot and the cat's feeding dish afforded the same opportunity - putting stuff in. Dr Reason created the 'Swiss cheese' model to explain human fallibility, which is made up of two approaches: the active (person) and the latent (system).¹

• Active failures - the unsafe acts committed by people who are in direct contact with the patient or system. They take a variety of forms: slips, lapses, fumbles, mistakes, and procedural violations.
•  Latent conditions - arise from decisions made by management, etc, and these decisions have the potential for introducing failure into the system. For example these include time pressure, under staffing and inadequate training.

The 'Swiss cheese' model illustrates the trajectory of an accident. The holes in the Swiss cheese represent the failures in the system's defences that allow a hazard to pass through. Error is a combination of human and system failures. Even the best of us can make mistakes, so it is important that defences are in place to ensure that any mistakes due to human error are made less likely.

Incident reporting system

Incident reporting has proved to be a useful tool in preventing error in high-risk industries, such as aviation, nuclear and petro-chemical industries. Healthcare operations should have a systematic approach where staff know what type of incidents to report, what information is required and how to learn from it. Staff should feel they can report incidents without the fear of personal reprimand. A positive patient safety culture is one that has open communication, mutual trust, shared perceptions of the importance of safety and confidence in the efficacy of preventative measures.

So what have we learned?

All dental care providers can make mistakes, hopefully minor ones. What's important is being honest, owning up and reporting the mistakes so that lessons can be learned. The best dentists should be able to admit making mistakes and see the process as a learning tool. Prepare yourself by finding out about reporting systems. Read and learn from risk management publications.

Endnotes

Susan Willatt is a full time Dento-Legal Adviser at Dental Protection

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