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It sounds like negligence to me. Speak to a solicitor who specialises in this, if you have a case they will take it on, sadly it happens far too often in the NHS.
That's no offence to the thousands of good people, but my dad sued and got a 50k settlement, due to miss-teatment of his late wife.
Unfortunalty in this particular instance, aside from from the pay out, the very highly paid 'consultant' at fault in question, simply got moved sideways rather than struck off.
I have nothing to add beyond noting that, yet again, when you really need an expert someone on STW will step up and provide real help.
Kudos @defblade.
As someone who delivers therapeutic injections I always check the box it is in and the individual vials. Before delivering the injection the batch number, expiry date and dosage administered at written in my notes. I do this before the injection to make sure what I'm going to inject it in date and correct.
I work on the premise you can't be too careful .......
Not the first to say this but there is a clear system there (we use the same in a vet practice) where the dispenser marks and then someone double checks - this has not been followed.
Also I’m somewhat surprised to see a tick not an initial. If you’re looking to have a chain you can follow when something goes wrong then these should surely be initially not just ticked?
This goes back to my original point in the its never a single mistake which causes a SI/Datix.
Wrong label put on bottle
Second check process has broken down
Nurse who injected didnt check that the bottle matched the label etc
When the investigation happens I would be willing to bet there are staffing issues what have caused the second check not to have occurred and not simply due to someone not caring plus the nurse was doing more than they should.
To the pharmacists here, if there is no one to do that second check should the treatment not be dispensed or is it ok for it to be given?
Just noticed that my local pharmacy as well.
In my work this would likely be classed as a serious incident and investigated accordingly, i.e the more serious the incident the more senior the investigators.
This error meets the threshold of moderate harm and therefore the pharmacy has a legal duty of candour.
Something is fundamentally wrong if that gets applied here.
A double (at least) system of checks failed.
The severity of that particular set of failures is immaterial to the system.
Basically "Oops, we accidentally picked the one on the left of the correct item not the one on the right/aove/under...???"
Sounds horrendous, must be challenged. Matthew Syed's Black Box Thinking covers some of this, he argues there seems to be a complacency or hubris in (some parts) of the medical community that means that these types of issues are just shrugged off as 'these things happen' rather than a desire to learn and get better. cf the airline industry that gives the book its title.
https://www.goodreads.com/book/show/24611735-black-box-thinking
I'm surprised in this day and age that it relies on people reading and manually checking. I last worked actively in chemical distribution 10 years ago, but there were systems there where every drum was bar coded for product and batch number, the equivalent was on the pick sheet, and the operators had a handheld that you had to scan both on and would pick up any mismatch.
Just typed a long reply, and got 403 forbidden when I tried to post it.
So i'll split it into smaller chunks
To the pharmacists here, if there is no one to do that second check should the treatment not be dispensed or is it ok for it to be given?
It has to be ok, or in some places whole days would go by where no medicine could leave the pharmacy! As I've said before, there's a strong suggestion (which will probably appear in their SOPs) that if self-checking, you take a "mental break" and do something else to break your brain's chain of assumption between the 2 steps. It can be difficult, especially if you have an impatient patient watching you walk away from their tablets, but ignoring those pressures is part of working professionally.
Also I’m somewhat surprised to see a tick not an initial.
That's a squiggle, not a tick. They will know who makes that mark. It's difficult to get anything neat into the tiny boxes, not to mention writing it hundreds of times a day, so for most people, most of the time, it's squiggles... but we know whose squiggles they are!
he argues there seems to be a complacency or hubris in (some parts) of the medical community that means that these types of issues are just shrugged off as ‘these things happen’ rather than a desire to learn and get better.
To be fair, some people are like that. And the level of investigation we can realistically do, especially weeks after the incident took place, can be quite limited. So sometimes the best answer we can give is "these things happen/human error"... although we should then attempt steps to reduce the chances of it happening again.
There's a paragraph or 2 here about the pitfalls of computer checking. Seems to be the bit getting me the 403 for no reason I can see. So skip that!
And our problem (and Holy Grail) in pharmacy is, as I say to all new starters, "in pharmacy, perfection is just about acceptable." Everything needs to be 100% correct, 100% of the time. And even then, we will still get people complaining about something. I'm hoping the time I'm spending typing this helps people understand that perfection is not possible in any system that involves humans at any stage (someone has to program those computers, match the barcodes to the stock, etc) and so starting from a point of "strike 'em off!" is not helpful... it is even the opposite, as a fear of personal consequences for genuine human error leads to brushings-off and cover-ups rather than an open, learning, response.
And at the same time, I'm aware "lessons will be learned" is now perceived as a brush-off in its own right.
Here, though, there's enough suggestion from the pictures to say that this pretty definitely exceeds that... I'm afraid sometimes the investigation does throw up poor practise or negligence.
/end thread. I feel like I'm on twitter now!
it is even the opposite, as a fear of personal consequences for genuine human error leads to brushings-off and cover-ups rather than an open, learning, response.
which is also part of the Black Box premise - until culture changes so everything gets reported, then the culture remains of brushing off and cover up.
In the end the error is the error; once that happens the outcome is just luck. Reducing the seriousness of the investigation or corrective action because no-one actually got killed / seriously injured misses the chance to learn the lesson.
eg: H&S policy at work for example. If you fail to maintain a roof and a slate falls off and there's no-one there, it'll probably be marked down as 'oh, a slate clearly fell off, we'll bear that in mind next time we inspect the roof'. If it narrowly misses someone, it'll be dealt with straight away. If it hits and kills them......then the HSE are visiting and a world of pain. Same failure; what follows is pure damn luck and we shouldn't leave things to luck.
theotherjonv
In the end the error is the error; once that happens the outcome is just luck. Reducing the seriousness of the investigation or corrective action because no-one actually got killed / seriously injured misses the chance to learn the lesson.
eg: H&S policy at work for example. If you fail to maintain a roof and a slate falls off and there’s no-one there, it’ll probably be marked down as ‘oh, a slate clearly fell off, we’ll bear that in mind next time we inspect the roof’. If it narrowly misses someone, it’ll be dealt with straight away. If it hits and kills them……then the HSE are visiting and a world of pain. Same failure; what follows is pure damn luck and we shouldn’t leave things to luck.
I 100% agree.
Touch wood, I've never had any errors that had results as serious as this... but I'm fully aware, as are most pharmacists and I would say most other healthcare professionals, that it becomes a numbers game and a throw of the dice.
It's not flippant: perfection really is the minimum acceptable. I keep it in my head all day every day, constantly reviewing with a small part of me what might be done better/safer. But I'm also aware it's ultimately unobtainable.
Unfortunately (and it actually makes me a little sad), it's clear here that someone has let that mindset slip - whether briefly or routinely - and thereby caused others to suffer. Hopefully they will be able to learn and improve.
If anyone ever wonders why the pharmacy is taking so long - "it's only tablets" - please remember this thread and that there's a lot more going on back there than you may see!
Read this thread for a 3rd time now, and don't know what to say really.
Only what a huge cock up. I would defo report it and sue as well, Haloperidol is nasty stuff.
Hope the wife is ok now.
Some good advice from others here.
Good luck.
So someone else prepped an injection and someone else gave it?
This is why you don't give injections someone else has drawn up.
Haloperidol instead of B12. That's a good one!
Someone's not doing their 6 rights of medications.
This is why you don’t give injections someone else has drawn up.
Good luck vaccinating 65 million people 4 times each, over a period of a year or so.
Touch wood, I’ve never had any errors that had results as serious as this…
Whilst this is considered based on the "luck" of the error of the error not being immediately fatal it will never get better. Basically if someone dies or not is based on the alphabetic sorting and what lies to the left/right???
Whether someone dies or not should be irrelevant to the investigation because the potential exists both through not getting something a patient needs to stay alive or getting something that kills them.