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There but for the grace …

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7303.56 (Published 07 July 2001) Cite this as: BMJ 2001;323:56
  1. Neville W Goodman (Nev.W.Goodman{at}bris.ac.uk), consultant anaesthetist
  1. Bristol

    Itoo have injected the local anaesthetic bupivacaine into an intravenous cannula instead of into an epidural catheter. I have injected the antibiotic cefuroxime, thinking it was the anaesthetic thiopentone. I once failed to dissolve the full amount of thiopentone, and it took me a couple of cases to realise I was using an inappropriately dilute solution. I have flushed a cannula at the end of an operation only to realise that I had injected the muscle relaxant pancuronium instead of saline. What prevented me from injecting another muscle relaxant, suxamethonium, into a conscious patient was no more than the flip of a coin. Having injected the opioid fentanyl and the induction dose of anaesthetic, I reached for the suxamethonium syringe. There wasn't one, but there was another syringe labelled fentanyl that contained the suxamethonium. I have injected 15 000 units of heparin intravenously thinking it was 3000 units. This last was after checking with an experienced anaesthetic sister. When we read the label, we both saw what we expected to see rather than what was there.

    Once the front pages were full of people savaged by Dobermanns. What editors want now is blundering doctors.

    I have nearly made many other errors, but realised in time. I don't think my injection errors make up a bad catalogue—considering that they are spread over an anaesthetic career of nearly 24 years, they must make up a negligible percentage of injections given. Every anaesthetist I know admits to similar errors.

    There are only two conclusions to be drawn. Either anaesthetists are peculiarly careless and haphazard in their practice, or this type of error is inevitable. Given the nature of their practice and the knowledge that death comes easily on the end of a needle, I think it more likely that anaesthetists are peculiarly careful, even obsessive. Not only is this type of error inevitable, but inevitably some will have more important consequences than any of my errors. Inevitably, every now and again someone will die because of an anaesthetic injection error.

    Doctors are the current dangerous dogs. At one time, the front pages were full of people savaged by bull terriers and Dobermanns. People are still savaged by dogs, but the topic is no longer fashionable. What editors want now is blundering doctors. They want grieving families to say that these accidents in the NHS must stop. They give the impression that these disasters are something new. But they are not. I know of deaths resulting from accidents that did not even make the local papers, never mind the national press. These accidents were not covered up. They were investigated; reasons were sought and explanations given. They were not taken as evidence of national scandal, nor were they. Given the litany of large scale medical disasters over the last few years, and the introduction of clinical governance and clinical risk committees, it is far more likely that there are now fewer harmful incidents than before, even if the media slaver over the rapidly increasing number of complaints.

    When clinical governance was introduced, I thought that it would not be enough to stop bad practice. I asked chief medical officer Professor Liam Donaldson at an open meeting what we would do when clinical governance was up and running and still the media found cases of bad practice, as they always would. He replied that the media would find the ground already dug by clinical governance. However, recent events—vincristine into the spine, bupivacaine into a vein, pure nitrous oxide given to a child—show that it is the media who do the digging. And they always will.

    When the worry was dangerous dogs, new legislation was hurriedly introduced. It has proved difficult and unsatisfactory. Mr Milburn last week joined forces with the medical royal colleges in signing a seven-point pledge for quality and an end to the blame culture in the NHS. He said, “Medicine is not a perfect science. Even the best doctors can make the worst mistakes.” He added, “Of course the small minority of bad doctors should be dealt with promptly and fairly.” The media hunger for blundering doctors is still likely to mean that actions that any one of us could take on any working day with any patient could mean our careers ruined and our names on the front pages. It becomes a constant worry, and dare I say that it is the good doctors who worry, not the bad.

    All over the country, people are objecting to the siting of transmission masts for mobile telephones. There is no evidence that these cause harm, but as one parent said: “They got it wrong about BSE, so I don't believe they are safe.” This is a dangerous state of affairs when all experts, all those with knowledge are ignored. We must not ferment the same view of doctors. Yesterday's unquestioning trust in doctors might have been misplaced, and a healthy mistrust might be better. But a paranoid distrust, fuelled by the suggestion that we can have an error free NHS, serves no one.

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