Not again!

Preventing errors lies in redesign—not exhortation

Again, a young patient with leukaemia is dying, not from his disease, but from an erroneous intrathecal injection of vincristine, intended for intravenous use.1 Again, the newspapers express outrage; they count up to 13 identical cases over the past 15 years. The hospital apologises, again, and two doctors are suspended, pending “investigation.” The NHS explains; steps will be taken, again.

And trust erodes, again, as a confused public, grieving with the patient and his family, wonder if they are safe. Spurred by the headlines, each asks, again, “Could I be next?” The answer, of course, is, “Yes.”

Less than a year ago the chief medical officer of England's NHS, in a landmark report on threats to patient safety in the NHS, courageously labelled the problem of medical errors as pervasive and consequential. He promised progress and even specified this very error—intrathecal injection of intravenous chemotherapeutic agents—as one targeted for “zero” occurrences: not just safer, but perfectly safe.2 So how could this happen—again?

The answer is surprisingly mundane. It is this: we are human, and …