15 May 2009

Systems at fault

When things go wrong it is often the individual that takes the blame. Quite often there are additional factors. A nurse who gives a patient the wrong drug or drug dose will have to take responsibility for the mistake but it could be that the system was rushing her or that the system allowed her to be interrupted. Quite often the nurse will pay the price and the system carries on as before.

If a doctor is jetted in from abroad and gives the wrong dose of a drug he must take responsibility. If he gives ten times the dose it seems totally unacceptable. But if it is the first time he has worked in the UK and he is not familiar with the drugs he is given there are also problems with the system. No doctor should be permitted to work out-of-hours unsupervised in such circumstances. But how can you possibly give ten times the right dose? Surely common sense would dictate that there must be something wrong if you had to open ampoule after ampoule to make up such a large dose? After all most drug ampoules contain about one standard dose. You can be fairly sure of that wherever you work. Or could there possibly be yet another problem with the system that needs addressing?


sam said...

"10 times the doze"

How about 'maybe' the doctor is not actually a doctor but a hopeful imposter Dr G?! .. Who checks on that and how?

the a&e charge nurse said...

But were to draw the line, Dr Grumble?

Do we go back to the change in out of hours arrangements in 2004?

I am no expert on EU employment law but I imagine the whole thing is a bit of a nightmare.

The agency that finally hired Dr Ubani "Take Care Now" had already been warned by another agency (Cimarron Locum Agency) that there had been insufficient time to assess Dr Ubani's capabilities.

So we end up with a tired locum who has never worked a nightshift in the UK with a curious background (combining work as a GP and running a private clinic in 'aesthetic surgery') armed with a hypodermic full of a diamorphine.

Now even if medical standards DO vary across the EU, doctors should still at least understand the class of drugs they are dealing with - although, perhaps not the exact properties of every single agent within that class.

The entire story is a very sad tale indeed - it seems the system itself may well have contributed to the death of one patient with at least one other also harmed by this unfortunate chain of events.

Unknown said...

He didn't have to open ampoule after ampoule, the OOH company gave 3 strengths (in their standard OOH pack)
including a high dose one.

Tired, yes, charge nurse. And not accustomed to using diamorphine in
OOH work, if at all.

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