Sleep-deprivation, Slips and Safety

Here is an amusing story, at least my wife found it funny.

Yesterday I went out to mow my lawn.  I filled the fuel tank, and spent 20 minutes trying to get the bloody engine going – no go.  So, being an anaesthetic type I systematically tinkered with the plumbing to find the error.  After another hour of tinkering – still no go.  Hmmmm, what is going on and what does this have to do with medicine you ask?  Is this the most obscure diagnostic challenge ever?

After admitting defeat, I took my mower down to the local small-engine mechanic, who opened the fuel cap and smiled as he asked:  “Did you lend this to anybody lately?”   “Umm, no.  Why?” I asked….     “well somebody’s put diesel in it!”     DOH!!!!  I immediately realised where the error occured.  I had run out of fuel (petrol) a week or so earlier and taken the jerry-can to work as a reminder to refuel it on my way home.  My night shift was a shocker, 10 admissions, lots of sick people etc and I had stumbled into the service station as the sun was coming up en route to Dreamland and “fuelled up” my can.

So here is what I was thinking as I drove home from the mower-repair place yesterday:

• I often make minor errors in my day-to-day work. Simple things like draw up in the wrong size syringe, or put the wrong label on a chart. As a rule I usually catch myself, and correct the error as it occurs.
• So during this “shocker night” I made a few errors and recognized them, fixed them right away.  But how many slips did I make and not realise, carrying on, oblivious to the problem?
• Maybe I should go back and check those charts…..

Medical errors are common, mostly minor and inconsequential, but sometimes they lead to bad outcomes – occasionally disasters.  There are many factors associated with error: training, experience, fatigue, mental health, team dynamics, communication-styles.  I thought I would take a look at fatigue as this is something close to my heart – I have 2 boys under 2, work mostly nights and rarely sleep more than 4 hours in peace!  Most of this is self-inflicted, so no sympathy required, thanks.

This Study of New Zealand Anaesthetists shows how common fatigue-related error is, and how overworked we can be.  This BMJ study is just plain scary – shows that errors are common and can be disasterous, yet we are not good at acknowleging our errors – the more senior and more surgical we get – the worse, according to this BMJ article.  In fact when it comes to error prevention and performance, the aviation industry make us all look like amateurs.  The team environment mandated in commercial aviation is an example we should all follow.  How many times has a nurse or student saved your hide, or politely pointed out an error in the making?

This study of Paeds trainees from JAMA 2005 showed performance and vigilance at the end of a busy call week were similar to trainees with a blood alcohol level of 0.05%, which is the legal driving limit in Australia.

Anyway – you get my point.  Yawn.  We need to be self-aware, understand that we are far from infallible, and be prepared to tag out out when we know we might be getting to the point where error is likely to occur.  This can be hard to do in a small town, with extremely limited medical resources.

Food for thought, I am off to bed now.  Is it OK to give a baby promethazine cos’ Dad is doing a full list tomorrow?? (kidding)