Editor’s Notebook: Learning from a Close Call


November / December 2006

Editor’s Notebook

Learning from a Close Call

In October, I spent a couple of days caring for a friend undergoing high-dose chemotherapy and stem cell replacement as an outpatient. My responsibilities were very simple, and in performing the most clinical of my duties — dispensing medications — I committed an error. For his evening meds, I fished 8 or 10 pill bottles out of the worn paper bag in the backpack that made the daily trip to the medical center, thought I had found the two meds that were required for 7 p.m., and handed my friend one correct bottle and one that was wrong. I realized my mistake before he’d taken the wrong pill and traded with him for the correct bottle. Despite all of the articles I’ve read or edited about the Five Rights, barcoding, Swiss Cheese models of error, etc., I found myself sitting on the floor with a paper bag full of pill bottles, two notebooks of instructions and hand-written notes about my friend’s treatment, able to rely only on my own highly unreliable ability to pay attention and not screw up.

The disease for which my friend is being treated — amyloidosis — is rare, but this experience illustrates challenges that increasingly are common. As more care is delivered on an outpatient basis, and inpatient stays grow shorter, patients and their caregivers take responsibility for managing increasingly risky conditions and complex care. I can’t claim that complexity caused my error, but there were no double-checks for my process beyond the attention of the patient himself, who was so tired at the end of a long day, he nodded off peacefully every time I turned my back. Following the close call, I replaced the paper bag with a clear plastic zip-lock bag. The next caregiver on duty created an additional medication checklist to manage a regime that was scheduled to become significantly more complicated in the following few days.

I still have much to learn and perhaps to write about my friend’s experience: the methods he and his caregivers (who number 15) devised for managing communication and information, relationships among clinicians and lay caregivers when the lines between inpatient and outpatient blur, and the very practical side of issues such as privacy and liability among a large group of lay caregivers.

I’m delighted to say that my friend’s treatment has gone well. I have deep appreciation for the hard work that he did to prepare for and comply with a very demanding treatment protocol, for all of the caregivers, for clinicians at the medical center, and for the universal experience of human fallibility.