Whose fault is it anyway?

28 Mar 2018 | Medication Safety
Tagged medication safety patient story

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A patient story of preventable harm

Every now and then a personal story comes along to shock us. It forces us to shake our heads and demand an answer. It calls us to action.

Last year, a male patient was admitted to hospital for treatment. He was struggling to breathe and worsening by the day. In the past he’d had a serious and potentially life threatening reaction and the medication alert necklace he was wearing during his admission warned of this. The emergency team carefully documented his allergies, updated his notes and fastened a red warning bracelet around his wrist as an extra safety precaution.

A short while later in the medical ward, the patient was prescribed a medication he was allergic to. Over several days he was given five doses by four different nurses.

'What?' we all say, and rush for our retrospectoscope. Debate becomes active – system issues, consumer issues, human cognitive factors, professional competency issues, all of the above?

My mind strays to a massive, dimly lit hall, crammed with long rows of one-size-fits-all graduation gowns, reciting an oath 'above all, do no harm'. Hippocrates the father of medicine, may or may not have actually said this but it seems quite a good thing to say, doesn’t it?

Yet every day, even with the best intention to do no harm, it happens.

Around a quarter of people admitted to hospital are affected by medicine-related harm and almost a tenth of people in the community report an error in medicines they’ve recently been given. So we collectively ask - how does this happen and whose fault is it?

On one hand, in quality and safety literature, an emerging conversation is encouraging us to reduce harm by shifting our focus to what we do well. But on the other hand we simply can’t look the other way. We need a balance and we must keep paying attention.

One preventable harm is one too many.

Internationally, a global challenge has emerged. On the basis that every person around the world will at some point in their life take medicines, and that unsafe practices and errors are a leading cause of avoidable medicine-related harm, the World Health Organization has launched a five-year patient safety challenge to reduce the harm associated with medicines globally.

We are all part of this world. And whether or not one event in a complex system is or isn’t my fault, safety is my responsibility. Safety is everyone’s responsibility.

So the question then becomes, not whose fault is it… but what can I do?

With special thanks to Wally and the Northland team for the willingness and courage to share this story. See Wally's full story on the medication safety programme page.


Author: Dee Alexander, project manager, medication safety programme

Last updated 29/03/2018