Rapid responses are electronic comments to the editor. They enable our users
to debate issues raised in articles published on bmj.com. A rapid response
is first posted online. If you need the URL (web address) of an individual
response, simply click on the response headline and copy the URL from the
browser window. A proportion of responses will, after editing, be published
online and in the print journal as letters, which are indexed in PubMed.
Rapid responses are not indexed in PubMed and they are not journal articles.
The BMJ reserves the right to remove responses which are being
wilfully misrepresented as published articles or when it is brought to our
attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not
including references and author details. We will no longer post responses
that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I know what someone did with their serious "close call" 14 years ago -- they
hid the fact. An intern who was 3 weeks out of medical school ordered
Clonidine 1.0 mg (not the correct dose of 0.1 mg) over the phone to the
nurse in the middle of the night for a hypertensive patient. Many layers of
"defense" did not stop the patient from being awakened and given 10 tablets
that took three swallows.
Almost no blood remained in that interns face when the pharmacist
called in the morning to strongly suggest that the intern should change
his erroneous prescription. Any remaining blood in his face quickly left
when the nurse paged the intern to say the patient felt dizzy and fell on
the way to the bathroom. The intern did not have to hurry, because
otherwise the patient was stable and no permanent harm was done.
Once recovered, the shame of discovery only prompted self regulation,
but he did not tell anyone. The intern created the "two-foot rule" for
himself. He now provided phone orders at night only after he was standing
on two feet.
Years later, the intern uses this story to educate other medical
students, residents, nursing students, and pharmacy students to be
"mindful" of the error-facillitating systems around them. The story seems
to help students recall stories about their colleague's errors...
14 years ago, regrettably, I know what I did with my error...
Dear George Dunea and other BMJ readers:
I know what someone did with their serious "close call" 14 years ago -- they
hid the fact. An intern who was 3 weeks out of medical school ordered
Clonidine 1.0 mg (not the correct dose of 0.1 mg) over the phone to the
nurse in the middle of the night for a hypertensive patient. Many layers of
"defense" did not stop the patient from being awakened and given 10 tablets
that took three swallows.
Almost no blood remained in that interns face when the pharmacist
called in the morning to strongly suggest that the intern should change
his erroneous prescription. Any remaining blood in his face quickly left
when the nurse paged the intern to say the patient felt dizzy and fell on
the way to the bathroom. The intern did not have to hurry, because
otherwise the patient was stable and no permanent harm was done.
Once recovered, the shame of discovery only prompted self regulation,
but he did not tell anyone. The intern created the "two-foot rule" for
himself. He now provided phone orders at night only after he was standing
on two feet.
Years later, the intern uses this story to educate other medical
students, residents, nursing students, and pharmacy students to be
"mindful" of the error-facillitating systems around them. The story seems
to help students recall stories about their colleague's errors...
(See more information on how to teach clinical personnel about error
analysis and avoidance at:
http://www.dcs.gla.ac.uk/~johnson/papers/HECS_99/Gosbee.htm)
Competing interests: No competing interests