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Kaleidoscope of the Heart: Tell others about your oversights

Rika Kayama (Mainichi)

Even though I've been doing this job for decades, there are still times when my heart begins to race. However, this is not because I'm excited. It's because I feel like I'm about to make a mistake, or do something dangerous.

    For example, such moments include forgetting to ask a patient an important question, which could potentially result in failing to detect a major illness. Or if I get the name of a drug wrong, and find myself on the verge of entering the wrong drug name into a patient's electronic medical chart.

    Once, in the days before electronic charts -- when they were still made of paper -- I had finished listening to a patient, prescribed some medicine and said, "See you next week," when I realized I had been using a chart belonging to a different patient with the same surname. The incident gave me chills and brought me out in a sweat.

    In the medical world, happenings of this nature which are not obvious errors, but which could potentially lead to a bigger mistake, are referred to as "incidents." Nowadays, it is encouraged to report any incidents and share them within the workplace. This is because it makes people realize that a certain type of blunder has happened and that they should be careful not to make the same oversight.

    Nevertheless, it takes courage to report an incident. Someone who read a report about a certain error might show disdain toward you, mentioning how it could have led to something more serious. Or, instead, you might be laughed at, being told that the mistake is not something a veteran professional should be making. Therefore, it is important to emphasize that if one shares an "incident," it will not have a negative effect on how they are evaluated.

    Having said all this though, there are sometimes occasions when an oversight can be laughed off. For instance, when I worked in a hospital in Hokkaido, I once answered the telephone in the outpatient department and the person at the other end said, "This is Yamada from the town of Miharashi." In a panic, I forwarded the phone call to the hospital director, saying that, "There's a phone call from the mayor of Mihara, Hiroshima Prefecture."

    When the phone call was over, the hospital director told me that the call was from someone called Yamada-san, in the local town of Miharashi, and that Yamada-san was about to come to the hospital due to having a cold. I can't remember exactly why I thought someone was calling all the way from Hiroshima Prefecture, but the happening apparently caused a number of doctors to laugh out loud at a meeting later that day.

    If a misunderstanding can be laughed off in this way, then that's fine. However, in some cases, errors in the medical world can potentially lead to huge accidents. Therefore, being open about oversights, and not hiding them, is obviously an effective way to stop them from happening again.

    So let's be open and try not to bury embarrassing oversights. This is a philosophy that could be helpful in other industries, as well as in everyday life. (By Rika Kayama, psychiatrist)

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