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Why is the nurse criminally negligent, but not the company or programmers which made the software that runs the automated medicine cabinet? Or the hospital adm
by phaedrus 5y ago
Why is the nurse criminally negligent, but not the company or programmers which made the software that runs the automated medicine cabinet? Or the hospital administration who failed to recognize and do something to correct the systemic problem of why constant "overrides" are needed to complete normal tasks?
Edit: maybe drug companies are even partly responsible for confusing names & the whole system of generic versus trade names (as it seems this incident wouldn't have happened if the generic name were the only name by which the substance was known).
I'm not saying any of the above should be. I just think we should compare and contrast the medical profession with aviation. The reason the accident rate is so low in commercial aviation is a systems approach to safety. In the medical profession it's all about machismo and individual responsibility - which doesn't lead to continual improvement as an industry.
- bigDinosaur 5y agoYou are correct. Robert Wachter has written a lot on this (see his The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age) and it's a common error to simply blame someone like a nurse for administering the incorrect medicine as opposed to seeing how that situation came to be. Healthcare has a lot to learn from how similar things are investigated in the aviation industry (note: that doesn't mean nurses get absolved of everything, just that even apparently insanely stupid mistakes are often the result of swiss-cheese style errors).