Not again!
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7281.247 (Published 03 February 2001) Cite this as: BMJ 2001;322:247All rapid responses
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Editor,
”NOT AGAIN”: -NOT AGAIN!
As I read Professor Burwick’s leading article “Not Again” I was just
about to congratulate him on erudite exposition, which should be widely
available to the general public and politicians, until I came to the last
clause which ruined it. “Freedom from injury” implies absolute avoidance
of risk; an impossible goal. There are two reasons for this.
First, the
practicalities of the law of diminishing returns mean that eventually
sufficient resources will no longer available to eliminate the last
remaining risk.
Secondly, concentration on one issue almost inevitably
leads to transfer of risk. This may lead to increase in overall risk, an
example of which is almost certainly the over-reaction of Government and
RailTrack to the Hatfield Railway accident, or to a smaller residual risk,
as one could envisage might apply to Professor Burwick’s example. Whilst
the use of different fittings will prevent many disasters, just
occasionally in the heat of the moment where speed is essentially a
universal connection might save a life which would otherwise have been
lost. That is not to say Professor Berwick’s example is invalid, but to
recognise an otherwise highly effective measure might itself have created
a disproportionately smaller but nevertheless real risk. To re-write the
saying, Professor Berwick’s means are justified but his end is
unachievable. Once again the unattainable is presented as the attainable.
A society that cannot accept the residual hazard taking the rough with the
smooth is indeed a sick one.
Yours sincerely
C K CONNOLLY
CONSULTANT PHYSICIAN
"RailTrack" may be replaced by "others"
Competing interests: No competing interests
"The problem arises not because of negligence but from lack of
experience and juniority. "
Oh dear.
Much of the practice detailed is clearly good, and a determined
effort to avoid a known risk, but the closing part of the posting reveals
that the underlying belief - that these repeated accidents won't happen as
long as enough care is taken - still persists.
Re-engineer the systems so that a monkey cannot get it wrong, never
mind a "junior" doctor - or a locum consultant who has never worked there.
Then we can feel safe. Saf_er_ that is.
Competing interests: No competing interests
to criticise individuals for proceeding when unsure is a little
unfair.
medicine is an uncertain business. at a guess, i would say that i am
"certain" i am doing "the right thing" in less than a quarter of my daily
activities as an anaesthetist.
Good evidence doesn't exist for much of what we do as doctors, and
applying "good" population based evidence to individual patients is
fraught with inaccuracies.
Virtually every doctor-patient interaction is an experiment
(physiological, pharmacological or psychological), with only degrees of
uncertainty regarding the outcome.
Competing interests: No competing interests
Not again!
I would fully endorse Donald Berwick’s view that the problem of
mistakes can only really be tackled by addressing systems rather than
human frailty. [1] However, I would caution against the belief that, "we
should be as safe in our hospitals as we are in our homes." After all,
about a third of all accidents happen in our homes.
Bernard A Foëx
Specialist Registrar in Emergency Medicine,
The Manchester Royal Infirmary,
Oxford Road
Manchester M13 9WL
1 Berwick,DM. Not again!. BMJ 2001;322:247-8.
Competing interests: No competing interests
The increased publicity of healthcare errors is leading many groups
to analyse problems and suggest solutions. Changing packaging, redesigning
equipment, direct supervision of staff and many other options have been
suggested for the vincristine situation alone. Yet to date few have
suggested that the culture may be the problem.
Within healthcare professions there can be a culture that denigrates
those that ask questions or who do not know the answer immediately every
time. Thankfully this is becoming less common, as colleagues in Medicines
Information departments can testify, but it has not been fully resolved.
I am certain that on occasion individuals are proceeding with
decisions and acts although they know they are unsure if it is correct.
This is in addition to the occasions where individuals have no knowledge
that they are making a mistake. This can occur because to stop and make
sure would infer that they did not know the correct answer and expose them
to criticism from colleagues, whether actual or supposed.
To admit you do not know is to show a weakness, yet it is also a sign
of strength. In addition to tackling the obvious changes already
suggested, healthcare professionals from all disciplines should
individually, collectively and institutionally take a critical look at the
culture they engender and ensure that professionals at all levels feel
safe and are encouraged to ask and learn.
Finally, those interested in pharmaceutical packaging and the
problems it may create may be interested by a website set up for precisely
these reasons. It can be found at www.patientpacks.com
No competing interests.
Competing interests: No competing interests
Editor- Donald M Berwick rightly points out in his article that we
need mechanisms to prevent such tragedies from happening. With the changes
in cancer management following the Calman-Hine report, this issue needs to
be
urgently looked at and nationally agreed guidance issued.
At Sidcup, we have been consciously aware of such errors and have for many
years introduced practical steps to prevent this from happening. The
central chemotherapy manufacturing unit labels intrathecal treatments "for
intrathecal use only" and Vincristine injections "fatal if given
intrathecally". The drugs are delivered in separate envelopes clearly
marked for intrathecal or intravenous route. We separate the intravenous
from the intrathecal
treatment in that specialist chemotherapy nurses give the intravenous and
haematology doctors the intrathecals. Intrathecal follows intravenous so
that vincristine is already given. Most importantly, no junior doctor is
allowed
to give intrathecal treatment without one of the haematology or oncolgy
consultants supervising the proceedure. The drugs are collected from
pharmacy by the specialist chemotherapy nurses and handed to the
consultant or to juniors in the consultant's presence. The consultant
checks the injections with the administering doctor and the electronic
prescription chart is signed by both.
The problem arises not because of negligence but from lack of experience
and juniority. By introducing such steps we are not only protecting the
patient but raising awareness and highlighting to the junior doctors the
fatal risk that comes from the simple switching of syringes.
Saad M B Rassam
Consultant in Haematology and Oncology
Queen Mary's Sidcup NHS Trust,
Frognal Avenue,
Sidcup,
Kent DA14 6LT
Competing interests: No competing interests
Dear Sir,
Donald Berwick is correct, a 'safe system' must be developed for
Vincristine administration (1).
A specific design change that could be quick, easy to introduce, and
relatively inexpensive would be to alter the way in which Vincristine is
supplied by the manufactures. Providing it in 1ml and 2 ml syringes is
asking for trouble.
The packaging should be totally redesigned so that it can never be
drawn up into a syringe at all, even in the pharmacy.This is no longer
necessary for intravenous administration and would therefore make it
incapable of being confused with say intrathecal Methotrexate.
One way of doing this would be to use a container such as the
antibiotic Imipenem 'Monovial'. In this way it would have to be mixed
through the built in transfer needle with a bag of intravenous fluid (say
100mls) to remove it from the vial.This would then be completely alien to
any doctor used to giving small volume intrathecal injections (rarely more
than 5mls )to attempt to do this somehow with a 100ml bag.
Another arrangement might be to have the vial and fluid bag supplied
already connected to each other and a linking tube opened just prior to
use to dilute it into say 100mls. Some intravenous drugs are already
supplied this way and pharmaceutical experts may have even better
techniques.
Vincristine is a relatively old drug and intravenous methods have
moved on since its introduction. There may be other established drugs with
safety problems that could be similarly improved.
Additional safety steps such as never giving the two drugs in the
same room, on the same day, or through the same luer connectors may help
but the supply of Vincristine in a special container,incapable of transfer
to any syringe, would always make sure it was extremely difficult to give
it intrathecally.
David K Whitaker
Consultant Anaesthetist
Conflict of interest: None
1. Berwick DM. Not Again! BMJ 2001;322: 247-248
Competing interests: No competing interests
Editor,
Everyday, on every ward, of every hospital in every country of the
world, lives are saved by the meticulous attention to detail of health
service staff. The details of which I talk are patient names, drug names
and prescription charts. I also suspect that every individual, who has
ever given a drug in error, has also given many thousands of drugs without
error as a result of this attention to detail.
As a third year medical student I spotted the almost identical
containers of lignocaine, saline and water for injections (1). Sadly, I
heeded the advice of my teachers to 'always make sure you read the label'.
I should have campaigned for a safer system for everyone; Perhaps a system
with different coloured bottles. This afterall, holds a certain common-
sense appeal.
The world has come to rely upon attention to detail to protect
against the gross failure of a system. Systems destined for disaster are
tolerated through custom and complacency. Individuals and organisations
shroud the forthcoming disasters in bureaucracy and accountability instead
of correcting the problem. It's such a shame when sometimes the answers
are so easy.
Chris Weiner
1. Minerva. BMJ 2001;322:308
Competing interests: No competing interests
Editor,
The BMJ editorial team must be congratulated upon their efforts to
address the problem of medical error1,2. Although they have rightly
publicised the excellent safety record of aviation as an example to the
medical field, it would seem the major areas identified within the
aviation safety programme as adaptable to medicine are, confidential
reporting systems, systems engineering and specific error-proof
ergonomics. Although important, these are more recent developments in
aviation safety and have not been primary drivers in the reduction of
aircraft accident statistics.
There are many contributors to aviation safety but among the basic
defences against human error in aircraft operation are, operation manuals,
the specification of standard operating procedures and the implementation
of mandatory occurrence reporting systems with appropriate investigation
and feedback.
All aircraft operators in the UK must produce an operating manual as
part of their application for a licence, it is produced following
specified guidance material in a standard format and must be inspected and
approved by the CAA. The manual specifies posts, responsibilities,
operations, training, procedures and even flight crew duty schemes. It is
a complex document but must be maintained, amended and be available as
well as used, by all flight crew. Although there may be some comparable
documents in NHS hospitals, I am sure that they are not standardised, as
detailed, nor approved centrally.
Standard operating procedures may vary within companies but must be
stated and their use assessed in the 6 monthly base checks completed in
the simulator by all pilots. A major part of such procedures is the use
of checklists and the verification of actions by the non-flying pilot.
The development of SOP’s has encouraged the full participation of junior
flight crew in the decision making process and in error detection.
Mandatory occurrence reporting requires the definition of reportable
events but does increase the probability of error reporting. By
categorising such reports and investigating basic causes, action can be
taken but it is essential that such data is collated centrally with a
requirement to analyse and publish results.
The certification of aircraft requires that no single system or
component should be flight critical. We need to be applying a similar
scrutiny to medical procedures – in a standardised fashion. Although the
infrequency of aircraft accidents makes it difficult to use their
statistics as a measure of safety, medicine is not yet in that position
and there is much that can be done by consideration of the data already
available in terms of the procedures required by aviation.
While I agree that to err is human, safety depends upon the depth of
defences against error3 and large organisations must realise the
importance of procedures in that process. Unfortunately, it would appear
that the NHS does not fully appreciate this need to adapt using best
practise from other safety models. Their Executive recently advised that a
non-Executive Director of the National Clinical Assessment Authority
needed to demonstrate “commitment to the NHS” and that 20 years of
international consultant activity in the medical and human factors aspects
of aviation safety regulation were insufficient for interview.
Ron A Pearson, Aeromedical and Occupational health Consultant
Room 22, Forward House, Birmingham Airport Cargo Centre, Coventry
Road, Elmdon, B26 3QT
1. Reducing Error, improving safety, BMJ 2000;320
2. Berwick DM. Not Again! BMJ 2001;322:247-8
3. Reason J. Human error: models and management. BMJ2000;320:768-70
Competing interests: No competing interests
Drug error due to reading error !
Drug labels are not always unambiguously readable. The size and colour of the labels but more importantly the font size of the prints in order to read the name of the drug , its ingredients as well as dosage are frequent reasons for reading errors leading to serious drug error and its consequences. The chances of medical error are manifold during emergencies. The aluminum blister foil used for packaging due to its reflective surface makes it even harder for one to read despite using glasses.
It is recommended that a magnifying glass of good quality should be used for reading small prints on the drug label or blister pack. The magnifying glass should be easily accessible in all areas where medications are being dispensed to patients or are being sorted for other purposes.
However, in addition to the precautions medical and nursing staff might take in order to avoid medication reading error due to above related problem, it is the moral duty of the pharmaceutical industry to improve the standards of labeling as well as bring about more clarity in the prints. They need to ensure that important information related to medications is easy to read and the readily identifiable.
Competing interests: No competing interests