Enter the maze

Oh no! Not again...

Dr rushing to emergency: From www.istockphoto.com

What a mess. There's flour all over the kitchen floor.

A fortnight ago I opened the cupboard to get sugar for my hot chocolate. As I pulled out the sugar, it knocked against the bag of flour which was too close to the edge... Luckily the bag didn't burst and I cleared it up quickly before anyone found out. Now it's two weeks later and exactly the same thing just happened to my brother. This time the bag did burst and it went everywhere. Worse still he wasn't alone, so now he's in big trouble for being so clumsy!

Was it his fault? Should he have been more careful? He didn't choose to put the sugar in a high cupboard with the flour.

Maybe it was my fault? I didn't choose to put the sugar there either. But I didn't tell anyone about the first time it happened. I didn't move the sugar to a lower cupboard so it was easier to reach either. So maybe it was my fault after all? I knew it was a problem, and I didn't do anything about it.

Now turn your attention to a local hospital.

James is a nurse, working in intensive care. Penny is really ill and is being given insulin by a machine that pumps it directly into her vein. The insulin is causing a side effect though - a drop in blood potassium level --- and that is life threatening. They don't have time to set up a second pump, so the doctor decides to stop the insulin for a while and to give a dose of potassium through a second tube controlled by the same pump. James sets up the bag of potassium and carefully programs the pump to deliver it, then turns his attention to his next task. A few minutes later, he glances at the pump again and realises that he forgot to release the clamp on the tube from the bag of potassium. Penny is still receiving insulin, not the potassium she urgently needs. He quickly releases the clamp, and the potassium starts to flow. An hour later, Penny's blood potassium levels are pretty much back to normal: she's still ill, but out of danger. Phew! Good job he noticed in time and no-one else knows about the mistake!.

Two weeks later, James' colleague, Julia, is on duty. She makes a similar mistake treating a different patient, Peter. Except that she doesn't notice her mistake until the bag of insulin has emptied. Because it took so long to spot, Peter needs emergency treatment. It's touch-and-go for a while, but luckily he eventually recovers.

Julia reports the incident through the hospital's incident reporting system, so at least it can be prevented from happening again. She is wracked with guilt for making the mistake, but also hopes fervently that she won't be blamed and so punished for what happened.

Why did it happen? There are a whole bunch of problems that are nothing to do with Julia. Why wasn't it standard practice to always have a second pump set up for critically ill patients in case such emergency treatment is needed? Why can't the pump detect which bag the fluid is being pumped from? Why isn't it really obvious whether the clamp is open or closed? If the first incident - a 'near miss' - had been reported perhaps some of these problems might have been spotted and fixed. How many other times has it happened but not reported?

What can we learn from this? One thing is that there are lots of ways of setting up and using systems, and some may well make them safer. Another is that reporting "near misses" is really important. They are a valuable source of learning that can alert other people to mistakes they might make and lead to a search for ways of making the system safer - but only if people tell others about them. Reporting near-misses can help prevent the same thing happening again.

This is just a story, but it's based on an account of a real incident...that has been reported and that might just save lives in the future.