For want of a nail
It's been a little while since I ventured out for a cooked breakfast, so I especially enjoyed this morning's offering (Cantina, My Lawley, Mamma's plate for $A20). Surrounded by my nearest and dearest, it was not hard to feel optimistic, relaxed and comfortable. It was a pleasing hiatus from the general doom and gloom that seems to have pervaded the year.
In keeping with the darkness, I've been ruminating about medical errors and mistakes (thankfully not of my doing) for many months. After breakfast, I was meandering through a local book store and chanced upon a nursery rhyme. . .
For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.
Medical errors are often like this, a cascade of seemingly minor oversights, each leading to greater problems, which eventually become insurmountable. It's no surprise that some of my colleagues (who are all generally obsessives in the first place) become trapped by the apparent risk that resides in each decision filled day.
2 comments:
perhaps a more foodie analogy is known as "The Swiss Cheese Phenomenon" ... it's actually a pretty poor analogy as i've never been able to see through a block of swiss cheese!
quote:
James Reason proposed the image of "Swiss cheese" to explain the occurrence of system failures, such as medical mishaps [1-5]. According to this metaphor, in a complex system, hazards are prevented from causing human losses by a series of barriers. Each barrier has unintended weaknesses, or holes – hence the similarity with Swiss cheese. These weaknesses are inconstant – i.e., the holes open and close at random. When by chance all holes are aligned, the hazard reaches the patient and causes harm ). This model draws attention to the health care system, as opposed to the individual, and to randomness, as opposed to deliberate action, in the occurrence of medical errors.
full text: http://www.biomedcentral.com/1472-6963/5/71
Grant,
Thanks for the swiss cheese analogy. I think I've heard it before, and I think it takes a little too much emphasis off the individual making decisions.
Quite often (if you read the medical defense magazines) there is a narrative / litany of cascading events. Though perhaps it is in their interest to make it seem this way, so the paranoid medico happily pays his / her ever increasing subscriptions on time. . .
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