Medical error: the plane truthBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1281 (Published 12 August 2008) Cite this as: BMJ 2008;337:a1281
- Robin E Ferner, director, West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham
“The complex sorrows of actions going wrong” was how Marianne Paget, a US sociologist, described medical error. The core of this BBC radio programme, introduced by the comedian, media commentator, and doctor Phil Hammond, was a story of tragedy that exemplified actions going wrong and the sorrows that follow.
Martin Bromiley is a pilot who in his professional life has taken a particular interest in human error. In 2005 his 37 year old wife Elaine went into a clinic for routine, day case sinus surgery. Something went wrong during intubation, and she died in the intensive care unit 13 days later. Mr Bromiley explained how his wife’s oxygen saturations dropped to 75%, then to 40%, and minutes ticked by with no one able to act effectively, until hypoxic brain damage was inevitable. He understood and at first accepted the explanations of the medical staff. “The …