Safety checks is apparently what it is all about. Have I flicked this switch, is the oil full up, is the gasoline gauge working, is the tail rudder wagging? Get the co-pilot to tick the boxes with you. Ok, let us do the same in medicine. So we now have two nurses ticking boxes that it is saline. Check. It is a 250 mls bag. Check. It has 40 mmols of potassium in it. Check. It is going over 30 minutes. Check. It is being given into the right arm. Check. The arm belongs to Mr. Morrison. Check. Mr. Morrison is happy to receive it. Check. Mr. Morrison has not had previous reaction to saline. Check. The doctor has prescribed it on the drug sheet. Check. Time on drug sheet matches time on pump. Check. Dose of saline matches on sheet and bag. Check. ...we could be here all day hearing about what two nurses did over a whole hour. One side of your brain must be wondering what a waste of nursing time. The other part of your brain (sold out and converted and radicalised by "apparent patient safety" mongers) argues that it is all for a good cause and we do not have enough of it yet.
So the nurses concur and the drip is underway. Those more astute among you and those with a tendency not to nod to sleep while reading blogs as these may have noted that the 40 mmol of potassium is being given rapidly over half an hour. While this can potentially cause death, two nurses, ticking boxes between them has not deterred this mortal prescription from reaching fruition. They aided and abetted it. Not just one, but two of them. Collusion if you ask me. Two held responsible for one. (in reality, neither feeling responsible for the act; each relying on the other "after all the other also checked, so it is not my fault" feeling).
So how do we prevent this from happening? Any manager can answer that question. "Get THREE nurses to verify every prescription". No, we can't spare extra nurses to do that job. "Ok, then get two doctors to verify every prescription!". The solutions reach new levels of insanity as more and more people passionately get involved with the dedicated view that errors need to be eradicated through system safeguards and even more system safeguards. Training up people and making them take responsibility for their actions are increasingly sacrilegious suggestions in the new NHS where the no blame culture means no one should be blamed or faulted with and it is all the bad system that has made us what we are. Dump accountability on someone else's garden when a head badly needs to roll.
Increasing number of people are finding it difficult to understand the fact that box ticking stops thought process. I think they are too busy ticking other boxes to think about this in the first place. Some even go to the extent of accusing doctors of being non-caring about patient safety. They ask, “Why can’t doctors who are paid less than pilots, do what those highly paid glamorous trend setters in aviation industry do?” Airline pilots have been telling medical people how to do their jobs. The pilot mentioned at that link is the one who landed the plane in an emergency on the Hudson river. While everyone listens to him enthusing medics to do safety checks and to feel free to override seniors' decisions as required, they hardly recognise the fact that the ability to glide a plane into the Hudson river during an emergency was thanks to intensive training and not safety checks. So the real question is how often does an emergency happen in medicine versus the aviation industry. True to my nature, I never waste time stating the obvious.
One of the reasons why the analogy is particularly endearing for many members of the public and some of the medical fraternity is due to the fact that at any one time, the pilot, is responsible for the lives of 250 people aboard the plane. He is perceived to be in an even more responsible position than a doctor because a doctor only holds one life in his hands at any one time. Even if you don't agree with it, I can see no other reason why the driver of a vehicle has to be paid more than a doctor. So it follows that the pilot is best suited to advice the doctor how to look after his patients, rather than the other way round. Otherwise you would have heard of the aviation industry taking tips from a doctor on how to fly a plane.
So why don’t doctors treat patients as planes?
Gauges: alcohol content full. Check.
Exhaust: Full of cigarette smoke. Check.
Tail rudder. Lovely tail. check.
Audio: No heart murmurs. Check.
Visual: Pretty ugly woman. Check.
The reason why this does not work is that the pilots are given healthy planes, not sick ones. The starting argument for the pilot is to merely confirm that all is well for the decidedly healthy plane. Try giving the pilot a plane that is not working and see if he can check boxes and find out the problem. Well, he may be able to find out what is not working( symptoms) , but why it is not working (diagnosis) is left to the well trained mechanics while the pilot tips his hat at a lovely stewardess and goes looking for a healthy plane. Can you imagine a pilot calling out “gauges check” 20 feet away from the ground in a nose diving plane? I don’t think safety check was on his mind right then! The doctor faced with a septic patient in renal failure with acidosis and jaundice will never diagnose leptospirosis in time if he did mere gauges check. He would be busy putting up the drip and oxygen and asking for the mechanic (senior review) to come and sort it all out for him while he moves to another ward for more clientele amenable to box ticking.
Screening healthy people and Treating ill people should not be mistaken for the same. The more I see of safety checks, guidelines and the box ticking , I can see where the expression, “think outside the box” came from. Please don’t make “boxes”. Make more "outsides" to leave medical trainees free to think outside the pathway. Every time. Not just when they feel like it. But to think outside the “pathway” every time in every patient. Which then makes one think, why restrict thought with pathways every time???