BMJ  2008;336:186-188 (26 January), doi:10.1136/bmj.39426.511759.AD

Feature

Patient safety

Safer by design

¹ BMJ, London WC1H 9JR

Thousands of patients each year are harmed by medical errors, many of which could be prevented. Alison Tonks reports on steps to make the NHS mistake-proof

The first 150 words of the full text of this article appear below.

While a badly designed chair might be a little uncomfortable, and a badly designed oven might test your ability to turn out evenly browned cakes, a badly designed piece of hospital equipment can kill you. In 2001, Wayne Jowett, a leukaemia patient in a UK hospital, died from an intrathecal injection of the intravenous drug vincristine. Intravenous and intraspinal connections were, and still are, interchangeable—a fundamental design flaw according to the chairman of the subsequent external inquiry.¹ A similar design flaw contributed to the death in 2004 of a new mother who was given a bolus of bupivacaine intravenously instead of into her epidural catheter.²

In 2003, 16 year old Natalie Dibden died of a head injury soon after falling out of a badly designed ambulance.^{3 4} These tragedies and many others would never have happened in a world where hospitals, equipment, drug packaging and information, computer systems, and patient transport . . . [Full text of this article]

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