Oops, or the uses of error

In a recent editorial by the esteemed JAW I was berated soundly and justifiably for failing to produce an editorial piece when it was my turn to do so. I made a mistake; an error of omission. My excuse that I was out of the country visiting relatives was not truly valid since I had ample warning that my turn was drawing near. The truth is that I prefer to procrastinate. If I write a piece too far ahead, I draft and redraft and fiddle until I have destroyed it. Writing is a bit like painting: if you add too much to it, it loses the original vision. It is a bit like surgery—too much fiddling gets you into trouble—as in, “I’ll just tidy up this corner” or, “I think I will put in one extra stitch,” and whoops, bleeding: an error of commission.

Surgical lore advises one to learn from each error and not repeat it, or as my mother used to say, “Let that be a lesson to you.”

Medical errors that result in harm to the patient have always attracted media attention, but apart from causing most of us to think, “There but for the grace of God…,” little is learnt from them by the profession as a whole. Near misses or mistakes that do not result in harm because of their nature or because they are recognized and rectified immediately are not reported or only reported within an institution such as a hospital. It appears that opportunities are being lost to learn from error and so to enhance prevention of errors for our whole profession.

If there were a central clearinghouse where near misses and mistakes could be reported, without any identifying information about the doctor or institution involved and particularly if suggestions about how the problem could be avoided in future, then there would be a chance for all of us to learn from each other. The anesthetists have done this very well already, making anesthesia a much safer undertaking than it was in the past.

Some of the preventive measures that are needed might involve pressuring manufacturers to change their methods—for instance supplying fluids that can be injected into the cerebrospinal fluid in a uniquely shaped vial. It might be sensible to design a spinal needle hub that will only fit a special syringe that is clearly marked as spinal only.

It may be that some physicians have evolved their own safety measures. For instance, when I took my cat for an annual checkup and immunization ($168 for your information), the vet said that she had lived in fear of injecting the clear liquid Euthanol by mistake, and so terminating Fluffy or Rover prematurely, until she hit on the idea of adding red coloring to the vial. Now if she is handed a syringe containing bright red liquid she knows that it is for one purpose only. There must be lots of good ideas out there that should be more widely known.

Have I learnt from my error of omission? Well, this editorial was handed in one week late.


Patricia M. Rebbeck, MB, ChB, FRCSC. Oops, or the uses of error. BCMJ, Vol. 44, No. 1, January, February, 2002, Page(s) 6 - Editorials.

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Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

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