Learning from Our Mistakes

// January 13th, 2009 // Allied Health Education, Pharmacy General, Pharmacy Technician

On January 6, 2009 I posted an entry “Funny Pharmacy Video Spoof – Pharmacy Man” and erroneously credited the song Piano Man to Elton John….whereas it was actually a song by Billy Joel.

Several days later, a reader, Mike Stegeman, sent me an email bringing this mistake to my attention. I have since corrected the post, but kept my original mistake posted (just crossed through Elton John’s name). There is a greater lesson to be learned by us all from this occurrence.

While this mistake was not life-endangering, as are many medication errors, it is natural to want to fix our mistakes and try to move forward without bringing any extra attention to them. In healthcare, however, I believe that when mistakes are made we must not only correct them, but they should be discussed openly in an effort to prevent similar mistakes from happening in the future. We can not learn from mistakes that are hidden or covered up, so let’s admit to our errors, correct them as soon as possible, and then be open about our mistakes so that others can learn. Providing proper credit to Billy Joel is important, but discussing errors made in healthcare settings (no matter how insignificant they may seem) could help prevent future medication errors from happening.

My apologies to Mr. Joel and thanks to Mr. Stegeman.

2 Responses to “Learning from Our Mistakes”

  1. Mike Stegeman says:
    January 13, 2009 at 11:34 am

    I have to say, that admitting our errors is a very important thing, especially in health care. Sure, there are small errors like making an IV in a 100cc bag of NS rather than a 50cc bag of NS, that is unfortunate, but usually hardly fatal. But every once in a while those mistakes can be so much worse, like compounding chemo in a super concentrated Saline solution (to use certain events in my home state as an example.)

    If we, as techs, and more importantly as health care professionals, are unwilling to admit to the smaller stuff when it happens, then there is little hope that the big stuff is going to be prevented.

    Also, who would have ever thought that an obsession with the song “Piano Man” would ever get me mentioned in someone’s blog?

  2. SARAH VEAL CPhT. says:
    January 16, 2009 at 4:21 pm

    I work as a pharmacy technician at a VA Hospital in Georgia. I am also part of a RCA (Root Cause Analysis) committee. This brings mistakes, med errors, and other incidents to the committee to research why it happened and to find a way to prevent it from happening again. I feel this is a very useful tool to provide the excellent customer service to our Veterans.

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