Preventing Medical Errors: Specifically for the Registered
Dietitian in all Health Care Settings Barbara Truitt, RD, LD/N
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Welcome This is a two hour requirement for our Registered
Dietitian Licensure in some states. This webinar will pose
challenging questions to you and at some points we will have
interactions with each other. We will review basics of medical
errors with examples and how we can avoid making medical errors
ourselves. We will discuss most healthcare disciplines, including
dietitians!
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Objectives Define Institute of Medicine (IOM) definition for
Error Describe the interplay between medical systems and
individuals that can lead to medical errors Distinguish a bad
outcome from a medical error Describe looks alike, sound alike
medications Describe The Joint Commission (TJC) do not use list of
abbreviations
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Who can make a medical error?
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According to IOM: Hospital errors rank between the fifth and
eighth leading cause of death (44,000 to 100,000), killing more
Americans than breast cancer (42,297), traffic accidents (43,458)
or AIDS (16,516)
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Who pays the price?
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me, you
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my family, friends, your family and friends
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Institute of Medicine (IOM)Definition Error: The failure to
complete a planned action as intended or the use of a wrong plan to
achieve an aim
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IOMs list of General Categories for Medical Errors Diagnostic
errors Treatment errors Prevention Other
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Diagnostic errors Error or delay in diagnosis Failure to employ
indicated tests Use of outmoded tests or therapy Failure to act on
results of monitoring or testing
https://www.premierinc.com/quality-safety/tools-
services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions
of key terms
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Treatment Error in the performance of an operation, procedure,
or test Error in administering the treatment Error in the dose or
method of using a drug Avoidable delay in treatment or in
responding to an abnormal test Inappropriate (not indicated)
https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/index_1.jsp#IOM-1
definitions of key terms
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Prevention Failure to provide prophylactic treatment Inadequate
monitoring or follow-up of treatment
https://www.premierinc.com/quality-safety/tools-
services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions
of key terms
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Other Failure of communication Equipment failure Other system
failure https://www.premierinc.com/quality-safety/tools-
services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions
of key terms
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How many medical error-related deaths do you think occur each
year? 50,000? 75,000? Over 90,000?
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Medical errors account for 98,000 deaths per year in the United
States
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Medical errors can lead to death- not everyone walks away
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Medication mistakes are a leading cause of death after traffic
accidents and the largest percentage of medical errors (CDC, LA
times)
1.Avoid removing medication labels from Rx and OTC bottles AND
do not mix medications in the same bottle 2.Follow directions on
the bottle EXACTLY how prescribed 3.Take medications either with or
without food and water 4.Do not mix Rx medications with herbal
supplements 5.Read labels when taking an OTC medication with an
Rx
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Easy to make? You decide!
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IOM-1 Medication errors: A large percentage of medical errors
are associated with medications. The National Coordinating Council
for Medication Error and Prevention (NCCMERP) has approved the
following working definitions specifically for medication errors:
Medication error: Any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication
is in the control of the healthcare professional, patient, or
consumer. Such events may be related to professional practice,
healthcare products, procedures, or systems including prescribing;
order communication; product labeling, packaging and nomenclature;
compounding; dispensing; distribution; administration; education;
monitoring; and use. Adverse drug event : An adverse drug event is
any injury resulting from a medical intervention related to a drug.
Examples of such injuries include heart rhythm disturbances,
diarrhea, fever, nausea and vomiting, renal failure, mental
confusion, rash, low blood pressure, and bleeding.
https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/index_1.jsp#IOM-1
definitions of key terms
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Medication errors can occur at any stage of medication
administration. These include: Ordering: wrong dose, wrong choice
of drug, Transcribing: wrong frequency of drug administration,
missed dose because medication is not transcribed Dispensing: drug
not sent in time to be administered at the time ordered, wrong
drug, wrong dose Administering: wrong dose of drug administered,
wrong technique used to administer the drug, and Monitoring: not
noting the effects of the given medication
https://www.premierinc.com/quality-safety/tools-
services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions
of key terms
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medical and medication errors can happen anywhere In the care
of healthcare professionals Pharmacy Family Friends Neighbors
Babysitters
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Can you tell the difference? Which one is red hots and which
one is Sudafed?
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Answer The first one is Sudafed Look how closely they resemble
each other, could they be mistaken in YOUR house?
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More . Which one are mints and which are medications?
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Answer The first one are the mints Once again, look how closely
they resemble each other See how easily an error can occur in your
home?
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Do you know about .? Sound-alike Look-alike
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Sound alike, look alike
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Patient brochure/website page: Ways You Can Help Your Family
Prevent Medical Errors!
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Other ways we and other health care professionals can advise
patients we come into contact with, suggest they: 1.Voice concerns
and all questions to the appropriate professional if it is out of
your scope 2. Question side effects of medications, especially new
ones 3. Prepare a list of all medicines they currently take and
keep it on them and/or bring it to all doctors and ER visits 4.
Request copies of labs and all test results
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Question Have you PERSONALLY encountered any medical errors
while a patient in a hospital or doctors office? ____ I have ____ I
have not
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Dietitians !
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Heres what the lawyers are saying . Doctor or Hospital
Liability for Negligence When a patient is under the care of a
physician while in a hospital or other facility, there is a duty
owed to the patient by the physician and the institution for
reasonable medical care. If a patient must follow a specific diet
plan, failure to adhere to the diet can result in medical
malpractice. Frequently, this type of malpractice occurs when there
is an error on the part of the facility. For instance, if a person
must receive a diabetic, diet plan the wrong meal may be provided
to the patient, resulting in serious injury. Additionally,
providing food and drink to a patient where there is an order not
to do so prior to surgery can result in malpractice if the patient
aspirates during the surgery. Other ways that liability may result
from failure of a physician or health facility to provide a
specific diet, is by the physician or health care provider to
properly obtain a full medical history. If there is no note made to
a patients chart about the restricted diet, a typical meal [REGULAR
DIET] may be served to the patient, causing injury. Finally, simple
neglect of the patients dietary requirements and restrictions may
result in medical malpractice.
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Patient Safety: Preventing Medical Errors course for nurses
Transcription errors which can cause a patient to receive an
incorrect or unordered treatment such as an erroneous procedure,
medication, activity, or diet
http://www.orlandohealth.com/pdf%20folder/patient%20s
afety.pdf
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Medical error potentials for the nutrition department: 1. Diet
orders 2. Food/drug interactions 3. Fluid restrictions 4. Food
allergies 5. Religious dietary restrictions 6. Patient preferences
7. Change in location/facility
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1. Diet order scenario Order received for Puree, thickened
liquids. The kitchen gets the order, does not clarify which level
of thickened is correct and gives the least restrictive: Nectar.
The actual diet order was for Honey and the patient aspirates, who
is responsible? Error!
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All parties hold some level of responsibility, however, the
kitchen will take the most punishment since they directly provided
the inappropriate order and did not clarify. Train all staff to
double check incomplete orders.
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Risks for incorrect diet orders There are different risks for
diet error, depending upon the nature of the patients diet plan.
For a diabetic, failure to adhere to a medically required diet plan
can result in the following: hyperglycemia kidney problems
ketoacidosis death
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Risks for diet errors (continued) For a person on a low sodium
or sodium free diet, failure to follow the plan can result in the
following: hypertension stroke heart attack death
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Risks for diet errors (continued) For individuals taking blood
thinning medications, failure to adhere to a specific diet plan can
cause: uncontrolled bleeding stroke death
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Registered dietitians cut hospital nutrition order errors
Registered dietitians (RDs) are faster and more accurate than other
hospital staff when entering physician-approved nutrition-related
orders, show study findings. "The difference in error rates
supports that RDs are qualified and knowledgeable at accurately
entering diet orders for the patients they have assessed," say Mary
Keith (St Michael's Hospital, Toronto, Ontario, Canada) and
colleagues. Following implementation of the new policy, each order
entered by an RD contained significantly fewer diet order errors
compared with those entered by registered nurses (RNs)and clerical
assistants. Writing in the Journal of the Academy of Nutrition and
Dietetics, the team concludes: "It is imperative that RD access to
electronic diet order entry systems be promoted and supported in
hospitals where these systems exist or are contemplated, as RDs are
critical players in the advancement of patient care."diet
http://www.news-medical.net/news/20120719/Registered-dietitians-cut-hospital-
nutrition-order-errors.aspx
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2. Drug-food interactions What is a drug-food interaction? A
drug-food interaction happens when the food you eat affects the
ingredients in a medicine you are taking so the medicine cannot
work the way it should. Drug-food interactions can happen with both
prescription and over-the-counter medicines, including antacids,
vitamins and iron pills.
http://familydoctor.org/familydoctor/en/drugs-procedures-devices/prescription-
medicines/drug-food-interactions.printerview.all.html
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Food/Drug Interaction Scenario Green leafy vegetables were
served to a patient who is on a blood thinner because the diet
clerk failed to enter the restriction of high Vitamin K foods.
Error! Staff needs education
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3. Fluid restriction scenario #1 The kitchen only counted
beverages given to a patient with a fluid restriction of 1000 ml
daily for his diagnosis of Congestive Heart Failure. He received
jello and soup on his lunch tray and a popsicle on his dinner tray.
Error!
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Fluid restriction scenario #2 An order for John Doe reads
1000ml fluid restriction. 1. What if the kitchen gives all 1000ml?
2. What if the kitchen followed facility protocol and gave half,
but then nursing didnt follow protocol and gave 1000ml? 3. What if
both gave 1000ml? 4. What if the nurses aide provides a water
pitcher to the patient? Error!
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How can we prevent this error from occurring again? Education
to all staff who handle fluids and interact with patients Enforcing
protocols to all participating departments Education to the
patient, family and caregivers
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4. Food allergy scenario Food allergies A patients diet order
comes down as Regular diet, allergy to soy. This patient received
many items with soy on her trays, because staff didnt learn how to
properly read food labels. The two ways allergens are to be listed
on a label are shown below: In parentheses after the name of the
ingredient: Example: lecithin (soy), flour (wheat), whey (milk) OR
In a separate list after or next to the ingredients list. Example:
Contains soy, wheat, and milk. 8 common allergens: Milk, Eggs, Fish
(such as flounder, bass, or cod),Crustacean shellfish (such as
crab, lobster, or shrimp), Tree nuts (such as almonds, walnuts, or
pecans), Peanuts, Wheat, Soybeans
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5. Religious diet restriction scenario Kosher: means more than
just do not serve meat and dairy at the same meal A patient
receives an item on his or her tray that does not meet their
request. Error!
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6. Patient preference scenario A patient tells the diet clerk
she is a vegetarian, the diet clerk not realizing the different
types of vegetarianism assumes no meat and hence sends milk and
eggs on her breakfast tray because she felt the patient didnt order
enough food. The diet clerk is confused and cant understand why the
patient is upset. The kitchen staff needs occasional in-services on
diets including all the different types of vegetarianism.
Error!
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7. Change in location scenario Monday 7am Mr. Jones was
discharged from room 300A, he was on a Regular diet. 8:30am Mr.
Smith was transferred into room 300-A, he is NPO for surgery at
2pm. 9:00am Mr. Jones breakfast tray was delivered to room 300A,
the tray passer did not check name band or verify patients name.
Mr. Smith did not know what NPO meant, so he ate the Regular
breakfast tray. When his nurse realized what happened, Mr. Smiths
surgery was postponed and his hospitalization was extended by one
day. Error!
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Charting .
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Question Do you abbreviate words or phrases in your patient
notes? __ Yes __ No __ Sometimes
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Find out what your facility has approved before
abbreviating
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Notes and Abbreviations Writing cals for calories or BW for
body weight may seem like harmless abbreviations, but until you are
sure it is a standardized abbreviation by your organization, it is
best to play it safe and s-p-e-l-l i-t o-u-t
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Misinterpretation Think of the types of abbreviations that
dietitians use most often PRO CHO IBW ABW (actual or adjusted body
weight ?) and many more
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Spell it out It may seem obvious between dietitians, but other
healthcare professionals working in the same environment may use
similar abbreviations, and it can cause confusion. For example: ADA
means: American Disabilities Act American Diabetes Association
American Dental Association and used to stand for American Dietetic
Association
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Abbreviations what does this note say? 31 yo female adm with
cc: CHF, ARF, HA, PE following tx for OB, ? CP, may need to be
transferred to CCU. Lets think about it
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Remember, For every medical abbreviation you find, there can be
up to ten or more terms Lets take a glance at just a few
BA means . Barium Baker Act Backache Benzyl Alcohol Bronchial
Asthma Brachial Artery
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BP means . Blood pressure Bathroom privileges Bedpan
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BS means . Bowel Sounds Bedside Breath Sounds
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Capital C means . Calorie Carbon Celsius Centigrade Clearance
(rate, renal) Compliance Concentration Cornea
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CC means . Cubic Centimeter Chief Complaint Cardiac
Catheterization Complications and Comorbidities With Meals (Latin)
Caucasian Child
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CCU means . Coronary Care Unit Critical Care Unit
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CP means . Cerebral Palsy Chest Pain
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DC means . Discharge Discontinue
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FX means . Fracture Function
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HA means . Headache Heart Attack Hahnium Hyaluronic Acid
Hemagglutinin Hearing Aide
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MR means . Magnetic resonance Medical records Mental
retardation
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OB means . Obstetrics Occult Blood Overactive Bladder
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PE means . Pleural Effusion Pulmonary Edema Pulmonary Embolism
Physical Exam Pelvic Exam Phenylephrine
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PT means . Patient Physical Therapy Posterior Tibial artery
pulse
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SX means . Signs Symptoms Surgery Suction
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TX means . Therapy Treatment Traction
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How confusing is this? Gluc. Glucose GT gait training GTT
glucose tolerance test gtt. Drop gtts. Drops
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Or this ? LLB long leg brace LLE left lower extremity LLL left
lower lung, lobe LLQ left lower quadrant-abdomen LML left middle
lung, lobe LUL left upper lung, lobe LUE left upper extremity LUQ
left upper quadrant
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Lets rewrite it ! 31 yo female admitted with chief complaint
(cc): Congetive Heart Failure (CHF), Acute Renal Failure, Headache,
Pulmonary Edema following treatment (tx) for Obstetric care, ?
Chest Pain, may need to be transferred to Coronary Care Unit. Is
that what you guessed?
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Communication In all work environments, communication is
crucial for preventing medical errors. Whether you are in a
hospital or have a private practice, communicating with other staff
is important for the well-being of your patients or clients.
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Miscommunication When miscommunication happens, it opens the
door for medical errors
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DOCUMENT
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When documenting: 1. Follow policies use facility approved
sources [diet manual, guidelines, abbreviations] 2. Use NCP, ADI 3.
Be clear, consistent, precise 4. Use evidenced based calculations
and recommendations, up-to-date references 5. Never cut and paste
6. Be sure you are in the correct chart
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Open references Have references ready so your calculations will
be consistent every time
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Am I in the right chart? Before you continue with correct
documentation, you may want to check are you in the correct
patients chart?
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Wrong chart scenario The RD goes to pick up a chart for Patient
A, and at the same time a nurse has a question about Patient B, so
the RD picks up that chart too. Then the RD gets a phone call, and
asked another question by another nurse. Finally they get back to
charting on Patient A in Patient B s chart.
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Simple, honest mistake, cross thru with a single line, write
error and initial, now the same situation can happen with
Electronic Charting.. The same mistake can happen with Electronic
Medical Records too. Clicked on Patient A to begin charting, but
Patient B s doctor calls and wants a supplement added. Resume
charting on Patient A in Patient B s record.
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Hints Organize your patient information by using checklists, to
do lists or create your own forms ..
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RD form/template To be certain you include everything you need
to in your notes, its a good idea to make a cheat sheet, template
form. On my cheat sheet, the following items are listed so I am
consistent with my charting: 1. Height, Weight, BMI 2. Diet order
& intake OR Enteral feeding order and tolerance, residuals 3.
Diagnosis, History, Labs, Skin condition 4. Edema, Braden Score 5.
Important MD, RN or other discipline comments about patients
condition
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Academy of Nutrition and Dietetics charting recommendations as
listed in their toolkits : Always do the following when documenting
on a patient
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At all times remember to: Check that you have the correct chart
before you write. Chart a patient's refusal to allow treatment. Be
sure to report this to the patient's physician. Write "late entry"
and the date and time if you forgot to document something. Write
often enough to tell the whole story. Chart preventive measures.
Chart contemporaneously (contemporaneous notes are credible).
[happening at the same time]
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At all times remember to: Write legibly, offering concise,
clear notes reflecting facts. Chart what you report to other
healthcare providers. Chart solutions as well as problems. Document
your observations. Write only what you see, hear, feel, or smell.
Encourage others to document relevant information that they share
with you. Document circumstances and handling of errors. Chart your
efforts to answer your patients' questions. Chart patient/family
teaching and response. Chart all referrals/support efforts.
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Academy of Nutrition and Dietetics charting recommendations as
listed in their toolkits : Never do the following when documenting
on a patient
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Do not: Chart a verbal order unless you have received one.
Chart a symptom (for instance: c/o excessive thirst), without also
charting what you did about it. Wait until the end of the day and
rely on memory. Ever alter a record. If you make an error, do mark
through it with one line, indicate you are making a correction, and
initial (or sign) and date.
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Do not: Document what someone else said they heard, saw, or
felt (unless the information is critical -- then quote and
attribute). Write trivia: "a good day." (What does that mean?) Be
imprecise. Avoid terms like "large amounts" and "appears." Write
your opinions. Blanket chart or pre-chart. It is considered fraud
to chart that you've done something you didn't do.
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Charting Scenario An RD visits their last patient of the day,
but forgets to write the chart note until the following morning.
Overnight, the MD ordered a consult of the same patient for the RD
to complete the next day. What should they do?
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Document both interactions with the patient, addressing
discrepancy in date on the first note. NEVER BACKDATE!
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Since the last RD note: Patient had surgery on his ankle He had
a HgbA1C drawn, result: 13 BUT, because the RD copied and pasted,
the follow up note did not reflect any of these events
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We actually ended the webinar here !
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Lets look at some Dietitian scenarios
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What if an RD meant to recommend an order for 250ml enteral
formula every six hours (sometimes written QID) but instead was
written as QD (which is not suppose to be used). What would happen?
Order recommendation scenario
Lets reverse it An RD meant to recommend an order for 250ml
enteral formula once a day(sometimes written QD, again not suppose
to be used) but instead was written as QID (four times a day) for a
new admission, 16 year old female, who has Anorexia Nervosa and
weighs only 55 pounds. What would happen? Pay attention to the key
facts in this example
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Refeeding Edema Abnormal labs Error!
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Education documentation scenario A patient is newly diagnosed
with type 2 diabetes. Upon visiting the patient, the RD provides
verbal information as well as educational handouts regarding blood
sugar monitoring, confirming the patients understanding. Months
later, the patient returns with complications of diabetes, stating
they never received any type of education on diabetes
management.
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In this case, what happens? The dietitians notes are pulled to
confirm that it was discussed.
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Or a note was not written If the RD did not document education
at all, he or she has no defense that it was provided. If its not
in the notes, it never happened
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Document, document, document! The best defense against medical
errors is proper documentation. If you say or do anything related
to a patient, put it into your notes for accountability.
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Learning new things. Changing to NCP? Changing to computerized
charting?
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Using NCP start slowly Pick a few simple ones to start with and
slowly learn some of the others Focus on nutrition problems, not
medical
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Signing and Dating Electronic medical records make changes to
the way we chart, making sure that all notes are properly signed
with the correct date of documentation is still an important step.
Be certain to your computer displays the correct date and time each
day.
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Nutrition Support Both parenteral and enteral nutrition support
are high-risk for medical errors. But would it be the dietitian
thats liable for these errors?
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What could go wrong Improper placement Tube blockage Infection
Blood sugar fluctuations Aspiration GI distress Malnutrition
Electrolyte imbalance Infusion discrepancies (bolus vs.
continuous)
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Under typical circumstances, any issues relating to the type,
amount, or rate of formula/solution could leave the dietitian
responsible for errors. Procedural errors will depend on the
facility.
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How to avoid complications: Monitor labs (especially
electrolytes) Address high levels of residuals Assess for
protein-energy-malnutrition Ensure understanding between staff
members regarding instruction Check orders
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Enteral feeding scenario The dietitian writes the order for an
enteral feeding through an Nasogastric-tube as 250ml, not
indicating whether it was bolus or continuous. A nurse reads the
order and assumes 250ml/hr rate. What do you think the dietitian
meant to order? What could happen?
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Of course the dietitian meant to write this order for a BOLUS
feeding, however, if the person who entered or transcribed the
order was in a hurry or had people talking to them or they just
didnt verify orders, mistakes like this can occur. If not caught:
The patient could aspirate Begin to vomit Have excessive diarrhea
Hyponatremia Stress the kidneys, etc .. Error!
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Be clear and concise Especially with nutrition support orders,
it is important to write them in a way that others can understand.
Never assume that someone knows what you mean be very clear!
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Always state full name of product, route, rate, how often and
if it does or does not include flushes. Example: Nutrition
Supplement Glucose 1.5, via Nasogastric Tube, 40 ml hour x 24
hours. This does not include flushes, refer to MD for flush
orders.
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NDT, NGT, NJT Why did I spell out Nasogatric Tube? There is a
big difference between Nasogastric Tube and Nasoduodenal and
Nasojejunal tube. Sometimes patients have more than one tube i.e.
trauma
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PEG, PEJ Do you know the differences in feeding which need to
be addressed with Percutaneous Endoscopic Gastrostomy (PEG) and
Percutaneous Endoscopic Jejunostomy (PEJ)? What is it?
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PEG tubes can allow for bolus feedings because formulas and
flushes are going directly into the stomach. PEJ tubes cannot allow
for bolus feedings because formulas and flushes are going directly
into the jejunum.
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Medications and Enteral Formula Enteral feeding may interfere
with certain medications. Though physicians and nursing staff are
also aware of these interactions, it is still important to make
note of the drugs. Typically, for drugs to be given on an empty
stomach, the feed should be stopped 30 minutes before and after
administration. Nurses are usually told not to add medications
while the feed is still running. Stop the feed, flush the tube with
water and flush after each drug before starting the feed again. It
is always a good idea for the dietitian to remind nurses of this
when this type of medicine is noticed.
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THIS IS WHERE THE ME PPT ENDED IN AUG 2013
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Prevention the best medicine Most medical errors are
preventable. The more you are aware of possible errors, the more
likely you are to catch them.
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In all of the scenarios that we looked at, did you pick up on
any ideas for preventing medical errors?
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1. Document, document, document!
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2. Communicate with staff
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3. Listen to your patients and/or clients
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Medical Errors in Health Care: Josie's Story
http://www.nursetogether.com/medical-
errors-in-health-care-josies-story
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This is a story of a woman who had her daughter in a burn
hospital and at some point during her care, she noticed weight
loss, thirst and a change in her eyes. She knew her daughter was
not right, the hospital wanted to discharge her and the mothers
concerns were not taken seriously. Her daughter, Josie, at age 18
months old, died from complications of dehydration.
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4. Individualize care
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5. Promote safety in the workplace
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6. Create routine to prevent gaps in work
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7. Acknowledge areas of improvement
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8. Report new issues (or new ideas)
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Medical errors may be simple and harmless, or major and
life-threatening. Doing what you can to prevent all errors can save
a life!
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Scope of Practice In hospitals, the role of the dietitian is
fairly cut-and-dry, but in smaller facilities, its easy for the
dietitian to become mixed up in other roles.
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Keeping boundaries For example, in a behavioral health
facility, dietitians may play more of a therapeutic role in
treatment. But where do you draw the line and refer to the
therapist?
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In a nursing home, is it the dietitians responsibility to turn
the patients to prevent decubitus wounds? Wound care is important,
but remember your role as the dietitian.
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The best thing to remember is that if it feels out of your
realm of expertise, it probably is. To ensure safety of your
patient or client, always reach out or refer.
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Summary Anyone dealing with a patient can cause a medical error
7 areas for the nutrition department where medical errors are most
likely going to occur: Diet orders Food-Drug interactions Fluid
restriction Food allergies Religious diet restrictions Patient
preferences Change in location Never backdate, its OK to write a
note the following day as long as you mention your interaction with
the patient was prior
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Summary - continued Always document, EVERY encounter with
patients Double check you are in the correct chart/record Organize
your information and thoughts on a charting template Create your
own worksheet, develop a routine so you dont miss anything Dont
make up your own abbreviations Spell out as much as possible Only
use facility approved resources
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Summary - continued Refer to ANDs charting recommendations of
Dos and Donts Use evidence-based, up-to-date references Be clear,
specific with recommendations, especially enteral Remember PEG, PEJ
differences, educate staff and medications which require TF to be
turned off Remember your scope of practice In-service staff often
Notify management of mistakes, learn from them Communicate
