A couple of weeks ago I committed a medical error. I meant to blog about it at the time but, uncharacteristically, something stayed my flighty keyboard fingers. I’m still not sure what it was that denied you the up-to-the-minute access I like to offer, but the following questions might have had something to do with it:
Will others think me stupid? Careless? Saddled with poor procedural infrastructure?
Might it implicate me should the case ever turn legal?
Will it make me feel even guiltier when you let your comments fly?
As I key out these questions, I’m wincing. They’re right on target. So what, then, changed my mind…?
In human hospitals, Morbidity and Mortality Rounds (“M & M’s,” for short) are popular for the way they dispassionately rehash the ways people sicken and die in hospitals. What could we have done better? How could patients have been relieved of suffering or even saved?
As a friend of mine likes to say, mistakes WILL happen. It’s how you react to them that counts. He has three rules to follow when these things happen. Ask yourself:
1-Is there something you could have done to prevent what happened?
2-What can you do to make sure it never happens again?
3-Now that you’ve completed steps one and two—get over it!
He’s big on following through on number three, convinced as he is that burnout unfairly relieves the world of doctors who would otherwise be the best at what they do—ironically, for caring enough to stress out about mistakes less sensitive souls shrug off as inevitable.
My “accident”? Relying on a weight in the chart to calculate the dose of Immiticide, the drug we use to kill heartworms in dogs.
The dog’s recorded weight, five days earlier, was 24 pounds. After fully depressing the plunger on the syringe it occurred to me (in a “nooooooooo” kind of moment) that the amount I’d just injected into him didn’t seem to make sense for his appearance.
A quick trip to the scale confirmed my fears: He weighed just 17 pounds. I’d just overdosed him by about 40%. A mad dash to the telephone later and Merial (the drug’s manufacturer) tried to talk me down off the ledge by reporting statistics for 100% overdoses with no apparent untoward effects.
Somehow that didn’t make me feel any better…not when severe pain at the injection site is the biggest side effect…not when this dog was apparently already suffering it…not when his increased pain was likely to be proportionate to the excess amount I’d overdosed him with.
Sure, the dog’s fine now. He received extra pain relievers and did better than I’d expected. And, yeah, he’s projected to do as well as any other heartworm infected dog, even after having received a whopping dose of parasitacide. Merial swears it’s going to be fine. But how did it happen and what could I have done differently?
1-I always calculate my doses twice for drugs I don’t use frequently (I use this one about six or seven times a year) and I didn’t forget this time. But…
2-I don’t always recheck my weights if only a few days have gone by. For drugs like this one, getting two weights is going to be my future standard (the first one was clearly erroneous, probably a simple scale malfunction or movement error).
3-And now that I’ve taken steps one and two, I’m going to be kind to myself and proceed directly to the third...and just get over it.
So what changed my mind when it comes to blogging about it? I guess it's the fact that sunlight is not just a great disinfectant...it can also spotlight the very human ways we commit errors. As with M&M Rounds, it might even shine a light on corrections others will adopt to prevent them from ever happening again...