Confessions of an anaesthetist - wrong drug, wrong route.
Many years ago when I was still a trainee I was on night shifts. I always found multiple night shifts difficult as I’m a very diurnal person and find it hard to sleep in the daytime. It was always the second night shift I found hardest, not the first.
At the end of one of them I was exhausted – it had been really busy and I hadn’t stopped. I was putting a major case on the table and all was going well. I was very much looking forward to 8am when I could hand over to a fresh pair of hands and crawl into my bed.
8am came and no one had shown up. The person taking over from me had a reputation for taking an extra 20 minutes or so to be punctual and on this day she lived up to her reputation. This irritated me.
At 0820 she finally arrived and stood in the doorway of the anaesthetic room talking at me for the next ten minutes. I continued working, was trying to listen and also suppressing the temptation to sharpen my voice, tell her to stop talking, go get changed and start work.
While this was going on I gave what I thought was diamorphine down the patient’s epidural. It wasn’t. It was metoprolol, which should go intravenously, not down an epidural. It was properly labelled, and I have no other excuse than being tired, distracted and irritated.
I realised what I had done immediately. I felt so ashamed, so guilty. I had bonded very well with the patient and the thought of doing them harm made me feel terrible. I felt angry with myself and at that point thought I was the worst doctor in the world.
I got onto the Internet as soon as I could and luckily it seems metoprolol doesn’t cause any neurotoxicity. The patient was absolutely fine and grateful for my care and attention. This made me feel even more guilty.
I published this on Twitter yesterday and there followed a lot of discussion about what factors make us make mistakes and why we don’t report our mistakes.
I never reported mine (well, maybe I have now). Much of the discussion about why we don’t report mistakes revolves around fear of repercussions and punishment. I do think this is true, but the main reason I didn’t was shame and embarrassment. Such a schoolboy error, but as no harm was done and no one else noticed it was much easier to stuff it into a dark corner of my soul rather than come clean.
Would I have reported this through an anonymous online tool where I wouldn’t have been identified? Probably. I think there are learning points from this incident, particularly how you should modify your behaviour when you’ve identified yourself at risk of making a mistake. HALT stands for hungry, angry, late and tired. I was at least three of those, and I’m sure my supply of Haribo brain food had run out by then.
The most important way of modifying your behaviour is to recognise you’re at risk of making a mistake. Slow down, tell someone, vocalise what you’re doing. Even if you’re a surgeon in the middle of an operation find a safe moment to stand back, look up, walk away from the field and take five minutes to gather your thoughts.
What did I learn from this? First of all to recognise when I’m at risk of making mistakes, and secondly now the last thought that goes through my head when I’m giving someone a drug is “is this the drug I think I’m giving, and is the patient allergic to what I’m about to give”. I ask myself it almost out loud. I’m still trying to learn how not to get distracted. I’m getting better.