Not in my name

Whilst I try to mainly limit myself to writing about healthcare-related issues, one of the reasons I started blogging was because I was fed up with people telling me that as an [educated] woman there were things I should want (sex, drugs and the ordination of women) and things I shouldn't want (marriage, children, self-respect, and the right not to sing Shine, Jesus, Shine) and I was especially fed up with being told this by nominally Catholic women claiming to speak on behalf of all Catholics. I am therefore delighted to discover that I am not the only person who believes in, strives to live by and supports the teaching of the Church. Catholic Women Rising is 'a place for practicing Catholic women who support the Church’s teaching on sexuality, contraception, abortion, marriage and the ordination of women, to stand up and be counted.'

While I'm on the subject, I should just take this opportunity to plug the vastly improved website of the Women's Section of the Pontifical Council for the Laity. This is definitely a website with something for everyone, from philosophy to book reviews (and probably philosophical book reviews as well), from current affairs to anthropology.

No-blame culture and the loss of the sense of sin

When I was last working in a hospital (probably this would be a good point at which to say that I am a pharmacist) I was informed that we operated under a 'no-blame culture'. The idea was that if mistakes were made then it was important to be honest about them so that steps could be taken to reduce the causes of error. The rationale is obvious: a dispensing error can have serious consequences, but if you are afraid that you (or one of your colleagues) might lose your job (or be sued) over it you are unlikely to report near-misses.

 

To a certain extent, this makes sense. By encouraging reporting of near-misses you can look at the systems involved and take steps to reduce errors. The pharmacy I worked in was, like most hospital pharmacies, badly laid-out (usually because clinical pharmacy services have expanded rapidly in the last 20 to 25 years and most hospitals are older than that) and extremely busy. We provided pharmacy services to the equivalent of 3 hospitals and effectively needed to employ one person full time just to answer the phone for non-clinical enquiries (not helped when the town council once made a typo in some communication and we started getting all their phone enquiries as well!). Errors are bound to creep in with a turnover of this size, and it is important that systems do not faciliate them. By reporting near-misses you can take steps such as keeping all your high-risk (to the patient) medicines such as methotrexate and warfarin on a separate shelf; separate out the 6 types of Sinemet tablets and the 5 variations on Epilim instead of sticking to strict alphabetical order; check, double-check and triple check everything, and stick massive posters in your fridge so that everyone is careful to quadruple check the insulin. Manufacturers usually help by making the packs different colours (although it must be confessed that some of them appear to be more concerned with brand identity than patient safety). So far, so good.

 

But a no-blame culture can only go so far. Sometimes an individual is at fault. It is easy to mix up your Sinemet, true, but it is easier still if you are talking whilst checking, thinking about something else, have already been shouted at by a consultant that morning, rely on your memory when you aren't really sure, or were out the night before. A chief pharmacist I know once went a delivered an official reprimand to a cupboard (in another department) because whoever had filled in the incident form had stated that the error was 'the fault of the cupboard for being untidy'.

 

Pope Pius XII said that the 'sin of the century is the loss of the sense of sin'. We are all too ready to blame systems, or cupboards, or the fact that we weren't concentrating on the consultant who shouted at us, or the workload. No-blame culture may help improve patient safety, but it doesn't address the need to take responsibility for our actions. Often, when a patient is waiting to go home, it is 'pharmacy' who is blamed for the fact that they can't leave yet. Leaving aside the many occasions when actually the doctor hasn't written the discharge prescription yet, and the times when the medicines have been dispensed and delivered to the ward and carefully locked in a the medicines cupboard, if 'pharmacy' as a whole is to blame, then whose fault is it? The chief pharmacist? The ward pharmacist? The ward technician? The dispensary manager? The pharmacy rececptionist? The administrator who approved too much annual leave at once?

 

Following the Francis report there have been complaints that no-one at Stafford hospital lost their job. This situation is not quite the same as a dispensing error which is a genuine mistake, because a long-term, widespread cover-up of abuse is not a mistake. But in both cases, somebody must be responsible; there is a perpetrator (or more than one). Whether or not that person should be sued, or sacked, or strung up is another issue. The point is that we all need to recognise that we aren't perfect, we make mistakes, we choose badly, sometimes deliberately; we need to look at ourselves and admit that some circumstances are not beyond our control. And we need to start doing this on the small scale because some of us have jobs where errors are a matter of life and death. Some of us don't, but stop and think about the last time you broke a plate and whether or not you said 'the plate broke' or the 'the plate got broken' rather than 'I dropped it'. The truth will set you free: trust me, I'm a pharmacist.

A Sunday morning rant

There are some things that really get on my nerves, and this morning there were rather a lot of them all in the same place. So, just to get this off my chest:

• Christmas is over. It is Lent, vestments are purple, the tabernacle is covered with purple. The altar and the ambo are adorned with purple. But for some reason there are Christmas banner things (white, with star and manger) hanging up, half way down the church.
• Electric guitars do not belong in mass. I can just about tolerate acoustic guitars (although to be honest if the organist is away I think I'd rather we just didn't have hymns) but not pink acoustic guitars and definitely not electric guitars.
• Go the mass is ended is a terrible hymn. If you're on the fence about it you've obviously never lived in the West Midlands.
• Children as old as 13 leaving mass to attend the Children's Liturgy. They leave before the Penitential Rite.
• Bidding prayers which focus almost exclusively on what is in the news this week. Pope Emeritus Benedict did get a mention this week, for the first time ever. I'm not saying that we shouldn't pray for the people who died in the hot air balloon crash, but it would be good if we also prayed for the Church, the clergy, vocations, our conversion, our government, the protection of marriage and the family...but don't worry, we have got the horsemeat scandal covered.
• Children coming back from their liturgy in the middle during the offertory and then, when the priest has already started the Eucharistic prayer, interrupting the mass to 'share' what they have learned about this morning. At least there were no notices given at this point today.
• EMHCs being given pieces of the host and standing there holding them while the priest continues and then all consuming the host when the priest does. If you aren't a fan of EMHCs you should skim the next couple of points because in my parish we suffer from a severe confusion of the respective roles of the clergy and the laity.
• EMHCs giving blessings to those who don't receive Holy Communion.
• Priests sitting in the congregation and not celebrating mass. And if there's another priest there we really don't need 5 EMHCs. But if I hadn't been introduced to him I wouldn't have known he was a priest.
• Cherrypicking from the new translation. The word is not 'all', it's 'many'. And we no longer 'go in peace to love and serve the Lord'.
• People staying in church for a natter after mass. Some kind volunteers are serving tea and coffee, and even biscuits, in another building: it's not as if you have nowhere to go!
• Incaica vestments. You know, stripey, woven, Latin American stoles.

I think that's enough to be going on with - I do feel better now. I hope I haven't ruined anyone's day. I will attempt to hold my tongue for the next 12 months or so.