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Uses of error: Clinical and cultural
EPONYM
4 5 6 7
Lazarus JH, Kokandi A. Thyroid disease in relation to pregnancy: a decade of change. Clin Endocrinol 2000; 53: 265–78. Franklyn JA. Management guidelines for hyperthyroidism. Baillières Clin Endocrinol Metab 1997; 11: 561–84. Levy EG. Treatment of Graves’ disease: the American way. Baillières Clin Endocrinol Metab 1997; 11; 585–95. Bartalena L, Marcocci C, Pinchera A. Treating severe Graves’
ophthalmopathy. Baillières Clin Endocrinol Metab 1997; 11: 521–36. Woeber KA. The year in review: The thyroid. Ann Intern Med 1999; 131: 959–62. 9 Taylor S. Robert Graves: the golden years of Irish medicine. London: Royal Society of Medicine Services Ltd, 1989: 1–160. 10 Coakley D. Robert Graves, evangelist of clinical medicine. Dublin: the Irish Endocrine Society, 1996: 9–102.
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Uses of error: Clinical and cultural My first major error occurred when I was a first year paediatric resident at an academic hospital. It was the end of a regular day in the neonatal intensive care unit. I had written an insulin prescription for a continuous infusion in a premature infant with hyperglycaemia, at a dose tenfold higher than intended. The prescribed infusion was started by the nurse after I left the building. Hypoglycaemia was discovered 1 hour later by the house officer on duty, who immediately removed the venous canula before clinical symptoms were present. I learned about the incident the next morning. I remember my relief and delight that the glucose had been checked: had I not ordered this myself when I prescribed the insulin? Yes, but it had been a narrow escape. I learnt never to rely on potentially dangerous drugs without built-in checks on prescribing. The second major error happened 1 year later in the paediatric intensive care unit. An 11-month-old boy had sublaryngeal granulomas after long-term endotracheal intubation, and could not be extubated without severe dyspnoea. This respiratory distress was evident during a spontaneous extubation on the afternoon before his death, when the intensivists had great difficulty in replacing the tube. Laryngotomy was discussed at the time, but a decision was postponed. 15 hours later, during my night duty, I received an emergency call. The boy was hypoxaemic and rapidly developed brachycardia. The anaesthesist on duty and I resuscitated the patient in vain. I asked the anaesthesiology resident to check the position of the tube by post-mortem laryngoscopy. We were aghast when we learned that the tip of the tube was in the esophageal lumen. It took me a couple of years to admit to myself that the lung sounds we had heard were the result of wishful hearing. The memory of a fatal error remains. Today, I am forewarned but not afraid when I treat children with upper airway obstruction. Ever since that experience I vigorously teach the importance of the free airway as the first principle of resuscitation. The third major error was a cultural one. It occurred when my wife and I lived in the Lake Titicaca Basin in the Peruvian Andes. I went there to study ethnic medicine and morbidity of rural highland children. We lived in a small adobe house in an ethnic Amerindian village 3850 m above sea level. One day a boy was born in our neighbours’ household. Unintentionally, and to our profound shock, we witnessed a case of infanticide. I wanted to conduct a household survey on this widespread practice, but the village council refused to grant permission. My intent to focus these interviews on a strong taboo almost resulted in our forced expulsion from the village. Several years later I documented a positive association between child mortality and sibling health status among Amerindians in Southern Peru. My view on the human condition in the Peruvian highlands changed and deepened during the years, and the experience shaped my motivation to work as a doctor caring for the helpless. It is tempting to speculate that my research interests in metabolism, hypoxia, and growth derive from the experiences of my major failures, just as it is true that my recent research interest in folates developed after my wife and I had an anencephalic fetus. Kees de Meer Department of Paediatrics Albert Schweitzer Ziekenhuis, Dordrecht, Netherlands
1796
THE LANCET • Vol 357 • June 2, 2001
4 5 6 7
Lazarus JH, Kokandi A. Thyroid disease in relation to pregnancy: a decade of change. Clin Endocrinol 2000; 53: 265–78. Franklyn JA. Management guidelines for hyperthyroidism. Baillières Clin Endocrinol Metab 1997; 11: 561–84. Levy EG. Treatment of Graves’ disease: the American way. Baillières Clin Endocrinol Metab 1997; 11; 585–95. Bartalena L, Marcocci C, Pinchera A. Treating severe Graves’
ophthalmopathy. Baillières Clin Endocrinol Metab 1997; 11: 521–36. Woeber KA. The year in review: The thyroid. Ann Intern Med 1999; 131: 959–62. 9 Taylor S. Robert Graves: the golden years of Irish medicine. London: Royal Society of Medicine Services Ltd, 1989: 1–160. 10 Coakley D. Robert Graves, evangelist of clinical medicine. Dublin: the Irish Endocrine Society, 1996: 9–102.
8
Uses of error: Clinical and cultural My first major error occurred when I was a first year paediatric resident at an academic hospital. It was the end of a regular day in the neonatal intensive care unit. I had written an insulin prescription for a continuous infusion in a premature infant with hyperglycaemia, at a dose tenfold higher than intended. The prescribed infusion was started by the nurse after I left the building. Hypoglycaemia was discovered 1 hour later by the house officer on duty, who immediately removed the venous canula before clinical symptoms were present. I learned about the incident the next morning. I remember my relief and delight that the glucose had been checked: had I not ordered this myself when I prescribed the insulin? Yes, but it had been a narrow escape. I learnt never to rely on potentially dangerous drugs without built-in checks on prescribing. The second major error happened 1 year later in the paediatric intensive care unit. An 11-month-old boy had sublaryngeal granulomas after long-term endotracheal intubation, and could not be extubated without severe dyspnoea. This respiratory distress was evident during a spontaneous extubation on the afternoon before his death, when the intensivists had great difficulty in replacing the tube. Laryngotomy was discussed at the time, but a decision was postponed. 15 hours later, during my night duty, I received an emergency call. The boy was hypoxaemic and rapidly developed brachycardia. The anaesthesist on duty and I resuscitated the patient in vain. I asked the anaesthesiology resident to check the position of the tube by post-mortem laryngoscopy. We were aghast when we learned that the tip of the tube was in the esophageal lumen. It took me a couple of years to admit to myself that the lung sounds we had heard were the result of wishful hearing. The memory of a fatal error remains. Today, I am forewarned but not afraid when I treat children with upper airway obstruction. Ever since that experience I vigorously teach the importance of the free airway as the first principle of resuscitation. The third major error was a cultural one. It occurred when my wife and I lived in the Lake Titicaca Basin in the Peruvian Andes. I went there to study ethnic medicine and morbidity of rural highland children. We lived in a small adobe house in an ethnic Amerindian village 3850 m above sea level. One day a boy was born in our neighbours’ household. Unintentionally, and to our profound shock, we witnessed a case of infanticide. I wanted to conduct a household survey on this widespread practice, but the village council refused to grant permission. My intent to focus these interviews on a strong taboo almost resulted in our forced expulsion from the village. Several years later I documented a positive association between child mortality and sibling health status among Amerindians in Southern Peru. My view on the human condition in the Peruvian highlands changed and deepened during the years, and the experience shaped my motivation to work as a doctor caring for the helpless. It is tempting to speculate that my research interests in metabolism, hypoxia, and growth derive from the experiences of my major failures, just as it is true that my recent research interest in folates developed after my wife and I had an anencephalic fetus. Kees de Meer Department of Paediatrics Albert Schweitzer Ziekenhuis, Dordrecht, Netherlands
1796
THE LANCET • Vol 357 • June 2, 2001