Focusing on our attitudes
By Caleb McNeil
Think about a time when you made a mistake. What was your response to that mistake, and how did it make you feel? Did that mistake mean anything about you? Did it indicate incompetence? Mistakes are incredibly important moments in our lives, ones that we don’t want to miss out on. They are not unexpected events, and they will happen … to all of us. Most of the time, they don’t lead to bad outcomes and we can fix them, ignore them, and move on without repercussions. But mistakes provide us with chances to learn and grow. Failing to recognize an error as an opportunity, to take hold of it, to analyze it, and then to share its lessons will limit its potential to make us all better. This is a story about a mistake … one that I made and one that I hope we all can learn from.
We were dispatched to a serious medical incident, and on arrival we found a male patient laying by a toilet with gasping respirations. As we scrambled to gather information, we learned that the patient had diabetes, and a quick glucose check showed dangerously low levels. With his body shutting down, he needed interventions and he needed them fast. Struggling to find IV access, we made one unsuccessful IV attempt. At that point, we began working on obtaining an intraosseous (IO) access, a procedure we use on critical patients when fluid or medication is needed immediately. With IO access, we use a medical drill to establish access for medications through a bone. I grabbed the kit, prepped the site, installed the appropriate needle … and hesitated.
Let’s back up a bit. I have been with my fire department for seven years and run a lot of calls where IOs were used. Several years ago, I was cleared to start IOs on medical calls, but up to this point I had never done one on a patient. I haven’t been avoiding them; I just have never been in the right position on the right calls.
On the morning of this call, we had a great morning meeting covering expectations and roles for the upcoming shift. During our discussion, we went over some pit crew assignments, delegating who would do what on critical calls. I was placed on getting the IV/IO access. I had been assigned this many times before, but the right call never came along where I could perform the skill. On this day, that would change.
So, there I was, with the site prepped and the needle about ready to connect to the drill … hesitating, I spun off the catheter and promptly drilled into the bone. I was handed the prepared bag of glucose to begin sending life-saving sugar into the patient’s body. Since I had removed the catheter of the IO, all that was left was the flat hub that drops into the drill, needle in the bone, with no way to connect the medication. Realizing my mistake, I told the medic the IO was no good. We quickly transitioned to the other leg and I drilled again. This time the skill was performed correctly, and we had a flowing bag of glucose. By the time we had carried him down four flights of stairs, his blood glucose levels had risen significantly and he was improving.
In the end, my mistake cost us only a few short moments to correct. However, there is no doubt that it was a mistake that could have had dire consequences. We could talk about the effects that lack of experience or stress had on performance, but what I want to talk about is our attitudes toward mistakes, what we believe mistakes say about us, and how we can better handle them when they happen.
I recently finished reading two books on human error. One, called Black Box Thinking (Syed, 2015), spoke about the difference between how the aviation industry and the medical industry approach error. Aviation used to be one of the most dangerous industries in the world, with crashes and accidents common. Facing down its problems, the industry made sweeping changes. It chose to treat the mistakes as learning opportunities and created a culture that did the same. To help accomplish this, it placed black boxes in all its commercial airlines, and anytime there was an incident, the boxes would be evaluated so that lessons could be learned. The industry also implemented massive changes in its approach to training, including placing pilots in difficult situations in flight simulators. These changes have flipped the script, turning aviation into one of the safest high-risk industries in the world.
In the book, aviation was compared to the medical field where preventable medical errors are one of the leading causes of death in the United States. These mistakes are responsible for hundreds of thousands of deaths every year. The most common of these errors is with medications: being incorrectly prescribed, improperly dosed, and incorrectly given. This is a known problem, yet it continues to happen on a large scale. It would be easy to pin these mistakes on the individual giving the medication, but the problem is much bigger than that: It is systemic and it is cultural.
In his book, The Human Contribution (Reason, 2008), author James Reason says, “Medical culture equates error with incompetence.” The result of this mindset is that errors are hidden until they become catastrophic. Reason’s conclusion is that errors occur all the time and should be expected. Most of these errors are easily fixed and cause no long-term problems. But, if the culture values the learning that comes from errors, then even small mistakes are brought to light and evaluated for what they can teach.
In aviation, people are encouraged to expose their errors and learn from them, whereas in medicine they are equated with incompetence and are hidden until they cannot be ignored. Then individual people are blamed for incompetence and held responsible. Systems and cultures can be created that recognize the inevitability of errors and seek to use them as opportunities to grow. Blaming the individual is missing a systemic problem. When only people are blamed, the learning is limited, systems don’t change, and the errors continue.
Where are we in the fire service? We should expect that errors will happen, and we should encourage people to bring them forward so that we can all learn from them.
So, here is what happened to me on my call: When I was placed on the IO assignment during our morning meeting, I knew that this was a skill that I had never done on a live patient before. I believed I could do it, but I didn’t feel 100% confident in my skills. Yet, I failed to express this concern to the crew. I fell prey to pride and ego and was afraid to expose myself as being less than an expert. There were two newer members on my crew that day, and I didn’t want to be the senior member who wasn’t good at something. I missed an opportunity to improve out of fear of being vulnerable. I should have raised my hand and admitted that I had never done an IO before and then pulled out the kit and reviewed it.
My next mistake was on the call. It should have been easy for me to verify with my crew that I had the correct location and was performing the skill properly. I would have had some oversight to stop me from doing the wrong thing. This would have ensured success for me and the patient. But I did not do this, choosing instead to protect my ego to the detriment of our patient and my crew.
How do you feel about your own mistakes, and what is your attitude when you watch someone else fail? Have you ever headed to a training just hoping you didn’t mess up because you were afraid of how people would view you? Or, have you been the person who causes that fear? There are times when we know the answers and are confident in our skills and times when we are uncomfortable and make mistakes. It’s time to change our mindset surrounding failure. If we are afraid to fail, we are afraid to learn. If we discourage others from failing, we hurt their growth. We need to approach training and failure with a mindset that is anxious to learn and know that mistakes are a part of that growth process.
If you have worked hard to build your skills, if you have earned respect by investing time in your craft, be careful how you treat those who are just starting that process. They need to know from you that it is okay to fail. They need to see you step forward on drills and fall on your face. It will free them to do the same. When there are moments that you are uncomfortable and when you come face to face with a weakness, don’t send your probies to do the drill first. Show them you are still learning too.
While a wonderful part of our culture, be careful how much you tease and make fun of someone, because there is a point where it will become too much. If you’re new to the job, you have likely had moments where you were expected to perform a skill as if you were an expert–when you failed and the jokes felt a little too personal. Persevere; keep on stepping up and falling on your face. Stay positive, and keep on working. Your mistakes will make you better if you embrace them.
We have all made mistakes, and we will continue to make them. Failure is a part of the never-ending process of growth and improvement. It will take courage to step forward and share a mistake, to be vulnerable, and to expose yourself to criticism. But, it will make us all better; it will begin to change our cultures. Our failures are our greatest opportunities; we should not miss them.
On the call that day, I’m thankful we were able to make access in another location and that my mistake didn’t prevent our patient from receiving the glucose he needed. But, I wish I had the courage to act differently prior to and during the call. I am humbled and reminded to practice, practice, practice and to speak up when I am unsure of something. Part of working as a team is not being afraid to ask for help when needed. Let’s take every opportunity to learn, approach training as a chance to grow, and see our mistakes as opportunities. When you see others fail, don’t vilify them for it. We need to change our culture. If we can change how we view mistakes and our response to them, we will emerge with a culture that benefits all of us.
Caleb McNeil is a firefighter/EMT with Castle Rock (CO) Fire and Rescue. He has a BA from Multnomah University in Portland, Oregon. He has been a firefighter for seven years and leads his department’s confined space rescue discipline
 Syed, Matthew. Black Box Thinking: Why Most People Never Learn from Their Mistakes–but Some Do. Portfolio Penguin, 2016.
 Reason, J. T. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Routledge, 2016.