Not again!: Preventing errors lies in redesign—not exhortation

摘要: Again, a young patient with leukaemia is dying, not from his disease, but an erroneous intrathecal injection of vincristine, intended for intravenous use.1 the newspapers express outrage; they count up to 13 identical cases over past 15 years. The hospital apologises, again, and two doctors are suspended, pending “investigation.” NHS explains; steps will be taken, again. And trust erodes, as confused public, grieving family, wonder if safe. Spurred by headlines, each asks, “Could I next?” answer, course, is, “Yes.” Less than year ago chief medical officer England's NHS, in landmark report on threats safety courageously labelled problem errors pervasive consequential. He promised progress even specified this very error—intrathecal chemotherapeutic agents—as one targeted “zero” occurrences: just safer, perfectly safe.2 So how could happen—again? The answer surprisingly mundane. It this: we human, …