Almost every year a patient dies because a doctor injects the wrong drug into the spine. Yet almost from the first time I gave a spinal injection, I have wondered why are they making this so hard!
Make Spinal Needles a different size to venous needles Then it would be physically impossible to inject the wrong drug into the spine.
Over the years, I have approached a number of bodies, including people connected with the King's Fund about developing a spinal needle with a different sized barrel to that used for venous drugs. Always the answer is the same "Not commercially viable". Because by the time you have developed, tested, persuaded doctors to use them and Trusts to buy them, Safe Spinal Needles would be an expensive White Elephant. There is no central body, neither in the King's Fund nor elsewhere that is interested in such ideas, and expecting such a thing from the DoH might be like expecting pigs (or swine) to fly.
I am sure that staff in the NHS have hundreds of such ideas. It has taken twenty years to stop potassium chloride being stored next sodium chloride on the worktop in the drugs room. In the meantime, how many people have died?
Safety needs safe design as well as safe procedures. There are plenty of incentives for such work, feeling good, a sense of achievement, knowing that you have made a difference, knowing that never again will such a mistake be made. The drawback, is that when people work for the sake of it, you cannot own, patent or monetise their ideas and the satisfaction that we all gain from the sense of a "A Job Well Done"
Thus it is "In a Money Driven World Good Ideas go to waste".
Copyright (c) Liz Miller
http://www.lizmiller.co.uk
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2 comments:
AH,common sense Liz, something sadly lacking in the upper echelons of the NHS, they are quite happy to spend hundreds of millions on "management consultants" but when it comes to patient safety,sod all:)
If people work because they love it, how can the modern apparatchik control their behaviour?
Goodness knows what might happen if people did what they enjoyed and was good for them - we might solve global warming, environment pollution, save the whale, and all live long and fulfilling lives.
Or have I become an idealist in my old age?
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