When is a Lesson Truly Learned?

When is a Lesson truly Learned?

A formal review into some mis-dosing in major hospitals has just been released. https://www.hcasa.asn.au/documents/211-full-report-independent-review-into-the-incorrect-dosing-of-cytarabine/file.

One section took my attention.

"81. The review panel established that it was routine practice for the xxx to issue new and updated protocols by the use of a group email. These emails are sent to the same email group irrespective of the nature of the protocol.

82. To alert staff, in this way, that a protocol had been updated because of an error in the previous version was an inappropriate means of communication.

83. The poor construct of the email, which failed to indicate that the Cytarabine dose in the previous version of the protocol was incorrect nor convey any sense of urgency, most likely led the recipients to regard it as routine in nature. This, coupled with the fact there was no follow up contact with the recipients to ensure that they were aware of its significance, significantly delayed the recognition that immediate action was required which resulted in the continued use of the incorrect protocol at xxx"

It raises questions about the actual end point of our involvement in the Action Plan to address a lesson. In this case "Advise all staff" may have been a reasonable action to plan, but its execution was poor. So how far do we have to go?

ISO9001-2015 indicates that the Action Plan should have a QA step. This is supported in many systems (such as Lessons Management Hub (https://www,lessonlearner.com.au)

But, practically, we have found that the effort in gathering the evidence of the compliant understanding from the action was a significant task, possibly as much as effort as the action plan in the first place.

But we have seen the evidence in this report of the dire consequences of it not being followed.