Margaret McCartney: Punishing individuals won’t prevent errorsBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1279 (Published 14 March 2017) Cite this as: BMJ 2017;356:j1279
After Warren Beatty and Faye Dunaway announced that La La Land rather than Moonlight had won the Oscar for best film, the two accountants from PricewaterhouseCoopers responsible for the results were told that they would never work at the awards again.
An error about Moonlight felt particularly pertinent to me. At the beginning of my career I was called in the middle of the night to flush a malfunctioning cannula. In those days the only member of staff qualified to deal with this was a doctor.
I was knackered. It was a small hour of the morning, and I had been awake for all of the past 24. I had a long list of urgent tasks to do, and I was being interrupted on my way to each. The ward was dark. The 5 ml tubes of saline were kept in a plastic box on a window ledge, for easy access.
I grabbed a saline tube, snapped off the lid, and drew it up into a syringe on my way to the bedside. As I leaned back on the swing door to open it—no hands, less hand washing required—a shaft of moonlight bathed my white coat and reflected the label back at me. The vial I had in my hands contained potassium chloride, not sodium chloride. I had been about to give a potentially lethal injection.
Had that moonlight not lit my path, I would probably not be working as a doctor today. It transpired that a member of staff had been tidying up and thought the vials were the same (they looked like they were). Trying to help, they added them to the same handy box.
Had that moonlight not lit my path, I would probably not be working as a doctor today
Decades later, this still replays in my regular nightmares. Had I made a fatal error, I would have undoubtedly been found guilty of manslaughter. But that would not have stopped it happening again. What did stop it was an overhaul of the system, making it as unlikely as possible.
By simply punishing the individuals at the end of a trail of errors—as the NHS so often does—we pretend to have fixed the problem. I am no fan of PricewaterhouseCoopers, but the best people to prevent future errors may be the people who nearly—or did—make them. Pretending otherwise: that’s la la land.
Competing interests: See www.bmj.com/about-bmj/freelance-contributors/margaret-mccartney.
Provenance and peer review: Commissioned; not externally peer reviewed.
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