Error Prone

It is the basic instinct of people who have suffered the loss of a loved one to want to blame someone for the loss. This inclination is particularly prevalent in medicine, where the consequences of a simple mistake can be fataL Consequently, I have often seen erroneous conclusions such as this one.

““We always knew it was negligence that killed Pop but now we have it in black and white.””

This is a statement from a relative following the inquest into the death of John Peter Taylor who died from constrictive pericarditis. A nurse had given him the wrong medication during his stay in hospital which had exacerbated his condition. The conclusion of the expert is quite different:

““The inadvertent administration of a tablet of [the drug] contributed to the irreversibility of his decline but was not the fundamental cause.”

“”

Translated: the wrong pill didn’t kill him – just made it harder to save his life. This is a long way from negligence. The desire to blame the nurse is very understandable, but not at all helpful. The simple fact of the matter is that the nurse involved should not have been able to given someone else’s medication to Mr. Taylor. It should have been impossible.

Consider the normal hospital medication system. A medicine chart is written out at the start of Mr. Taylor’s stay. He is Canadian, so some medicines may be unfamiliar to the doctor who is likely to be junior, busy and tired. The chart contains a large number of medications, many with similar names. The medicines are prepared in the treatment room and then taken to the patient. It is not uncommon for several patient’s drugs to be prepared at once. The nurse may not know the patient’s by sight, may have confused the medicines or simply forgotten to check the patient’s name. There may be several Mr. Taylors in the ward.

This is the common system used in hospitals – it is little wonder that medication errors are rife in this setting. Error theory dictates that human mistakes are guaranteed to occur unless there is a compulsory gateway or multiple gateways to capture errors. These are the sorts of checks and balances that airline pilots use. If airline pilots had the error rate of the medical profession, dozens of fully laden Jumbo jets would drop into the sea every day.

It is pointless to place blame on individuals while expecting an impossible standard of perfection. It simply will not happen and these sorts of mistakes will continue, ruining the lives of patients, relatives, doctors and nurses. The only way to deal with this sort of ingrained systemic error is to change the system, and make it as foolproof as possible without relying on perfect human performance. For instance:

• All scripts should be computerized. The computer should be able to recognise abnormal doses, contra-indicated uses and cross reactions and warn the doctor.
• Medicine is dispensed at the correct dose, with a printed sticker
• The bar code on the patient’s wrist must be matched by the barcode of the sticker on the drug receptacle (otherwise the computer will not mark it as given).

Congratulations! the error that contributed to Mr. Taylor’s demise cannot occur. All the technology to do the above is available right now (and has been available for ten years). It just costs money and political will.

The question that should be asked, then, is not “who is to blame?” but “why is this error occurring at all?” If we need to blame someone then I place blame squarely with the Minister of Health of the previous Labour government. Feel free to blame the current Minister of Health if nothing has changed in three years. I know I will.

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