A woman my age recently died at a hospital because she was given an intravenous paralyzing agent rather than the ordered anti-convulsant.  Ironically, she came to the hospital to discuss her anti-convulsants and anti-anxiety medications.  She had a brain tumor removed a month earlier.

We thought we are going to give one medicine, and we gave another medicine.”

You see, a drug got mislabelled in the hospital pharmacy and a paralyzing agent was put in the IV bag instead.  She was being monitored, but unfortunately, a fire alarm went off, so the nurses were distracted closing sliding doors.  Concatenation of problems.  The patient stopped breathing, nobody noticed until she had a cardiac arrest, and she was then taken off life support three days later.

Concatenation of problems, 1985.  Delta 191 coming in to land at DFW.  Thunderstorm in vicinity.  New Doppler Radar not ready.  No weatherman on duty.  Lightning strike ahead and rapid intensification of the storm.  Plane hits updraft and accelerates.  On the other side plane encounters a downdraft, driving it downward, altitude too low to recover, 137 died.

The hospital had now implemented several steps “to ensure that an error of this kind will not happen again in our facilities.”

If I hear “to ensure that an error of this kind will not happen again,” one more time, I will scream.

Or maybe die, if it happens to me.   What about other facilities?  Any other facility going to learn from this?  We learned from Delta’s disaster.

They include the creation of a “safety zone” where pharmacists and techs are working that is intended to eliminate distractions and the implementation of a new checking system for paralytic drugs.  Airline pilots have long had “sterile cockpits,” where nothing but the aircraft is discussed below 10,000 feet.  A decade ago, I proposed the same for radiologists, who are interrupted frequently.  I think clinicians should do the same.  Very few phone calls are so important that they are worth disrupting a clinician’s concentration when seeing a patient.

Three enemies of good medical care: hurry, fatigue, interruptions or distractions.  In my training, I heard the “giants” could work 36 hours, when I couldn’t.  I dreaded days on call, knowing I might be awake for 36 hours.  The “giants” could work without eating, too.  I couldn’t. The “giants” could take phone calls while seeing patients.  I would be called out of the office, pick up the phone, and hear, “hold for the doctor” (who had initiated the call).  Some of those doctors were my partners.  The call disrupted my consultation.  I said this lifestyle was unhealthy and bad and told to suck it up.  I wouldn’t and left.  I was proven right.  Being awake for 24 hours is equivalent to being drunk.

Medication errors are common; twenty years ago my hospital, where I was medical director, were dealing with them.  How does a paralytic drug, rarely used, get into an IV bag? That’s a system that needs to be fixed quickly.  Move these drugs far away from all others in the pharmacy.

People are fallible.  We all screw up.  We are hurried, fatigued and interrupted.  We multitask; far too much is expected from too few personnel in many hospitals.  I interrupted radiologists.  Nurses are frequently interrupted, often by false alarms and incessant beeping, which is distracting. We live in a noisy, fast-paced world, dealing with huge volumes of information simultaneously.  But our brains have not equipped to deal with such.  I am a slow processor; I shut down when encountering questions from two or three people simultaneously.  When everything is urgent, nothing is.

But the “giants” dealt with that.  I couldn’t.

Very old people may hit the accelerator mistakenly, not the brake.  But you can’t shift a car into reverse without having your foot on the brake. Is that perfect?  No, but it is a good safety mechanism.  Compare that with the history of Vincristine, used to treat leukemia.

“We must be certain that there never is a 14th patient who receives vincristine intrathecally (into the spinal fluid) by mistake.”  I am not quite exact with the quotation, and I can’t find the article in the literature, but such injection, completely preventable, is almost always fatal, often in children whose leukemia was curable.  “It is unspeakable that this should happen in this day and age…”  That was said in 2001, long after the first quotation.  Google the issue now, and there is a recent case report of three children, two of whom were thought to have Guillain-Barre syndrome. The problem hasn’t been fixed, and it should never occur. Why?  In one article, twenty different system fixes were suggested.  What is wrong with medicine?

Stuff happens, yes, but this stuff needed to stop happening decades ago.  We’ve known about fixing bad systems for a long time.  Are we making progress?

Answer:  I don’t know.  We might review all hospital deaths using an ordinal scale to determine the role of medical errors.  Sample hospitals, and we have an estimate with a decent margin of error.  Do it over time, and we know trends, as well as numbers and types.

Those of us who study these issues believe in “root cause analysis.”  We also believe patient safety requires senior management’s seeing the data and acting upon it.  This does not happen in too many instances.  Reports need to be compelling and readable:  significant errors should be written up, the results of the investigation disseminated.  Delta’s crash made dealing with wind shear a major priority.  The American Airlines crash in Little Rock highlighted “get there-itis,” despite a thunderstorm’s intensification in the area, with failure to deploy spoilers, a combination of hurry, weather and fatigue.  Back then, two-thirds of pilots polled said they would land during a thunderstorm.  They no longer do so.

Medicine will never be perfect.  As technology changes, as medicines change; as illness management changes, there will be new challenges.  We need to face those challenges head on, anticipate them, have a safe way to report close calls as well as errors, and make these known to everybody in the field.  There should be no embarrassment, no hiding, but there must be an analysis as to what went wrong, as is done in aviation, what must change, and how to prove efficacy.  Top management must be involved and buy into these systems.  While we shouldn’t tolerate violation of safety principles, inherent system design must make it easier to do what is right, more difficult to make errors.

My ideas have been in the public domain for well over a decade.  Perhaps they aren’t good enough.  That’s fine.  I’m not perfect.  Offer better ideas.  Then prove it.

Just don’t tell me about the  “giants.”  They created the problem.


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