Medicine
Human error
John Linklater
A young staff nurse faced the Hammersmith coroner last week and told him, in direct and collected terms, the story of a tragedy which resulted in the death of a child. When she had given her evidence and stepped outside, she broke down and wept unconsolably.
She had qualified as a State Registered Nurse in 1973 at one of our best teaching hospitals and had broadened her experience after that by serving for a year as an agency nurse. She then took up her studies again and had passed her final examinations in midwifery about a month before the fatal incident. It was the first unsupervised delivery which she had conducted as staff nurse and midwife in an isolation delivery ward of a famous London maternity hospital.
She was assisting a New Zealand surgeon to suture a vulval laceration from which the newly delivered mother was bleeding freely but she was conscious of her double responsibility and therefore kept the newborn baby under observation as well. It was she who informed the surgeon when it began to breathe with difficulty. Neonatal respiratory depression is a well-known after -effect of analgesics given to the mother during labour. The respiratory reflex may not yet be firmly established, and there is a substantial risk that such a child will simply stop breathing and die.
The surgeon paused to verify the nurse's report, as well as the time and dose of pethidine which the mother had previously received. He then authorised an injection of 0.5 milligrams-of nalorphine (N-allynor morphine) which is the competitive antagonist to the morphine and pethidine group of drugs and which is therefore their antidote. This antidote is manufactured by Wellcome Laboratories under their patented standard process as Lethidrone.
The nurse took down an ampoule of Lethidrone from the drug cupboard shelf, noted that it contained the adult dose of ten milligrams and replaced it. On the shelf immediately below, however, were clearly marked 0.5 milligram ampoules. The baby's condition began to improve soon after she had injected one of these.
In due course the surgeon left, and she found herself again alone in the ward with the mother, who was now comfortable, safe, relaxed and drowsy, and with the baby who was now breathing well. The nurse therefore began to clear up the blood-stained swabs, paper sheets and general disposable debris. She was just about to screw up a bundle for the incinerator when her eye again caught the empty glass ampoule with the name of Welcome Laboratories and Lanoxin 0.5 milligrams clearly etched on it.
She looked again, with horror. Lanoxin, as she perfectly well knew, is the Wellcome Laboratories trade name for their standardised cligoxin. She had somehow given the baby the wrong injection entirely.
The nurse at once rang the alarm bell and summoned the hospital emergency paediatric team, to whom she explained. Every effort was made to re-establish the status quo ante but the digoxin was relentlessly and progressively absorbed by the baby's heart muscles, which eventually stopped beating, and the baby died. She was quite unable to explain how, in the heat of stress, she had confused the two Wellcome ampoules and why she had broken hospital standing orders by giving the injection without having it first checked by another qualified nurse or by a doctor. She accordingly resigned her appointment.
The incident gives food for much sober reflection. All doctors and nurses have to be trusted with independent responsibility when they finally qualify, and the safety factor is usually related to the quality of the training. Sanity still prevails at the university at which that staff nurse had been trained, and she had subsequently seen many deliveries as demonstrations rand had, herself, conducted the required number under careful instruction.
The incident most accurately illustrates the unique nature of medical and nursing responsibility. The incident also demonstrates why the Hippocratic principle never, actually, to kill, remains a cornerstone of medical ethics. If this nurse had become accustomed to doing duty in the abortion chambers, even her high integrity might have been blunted by the sight of so much killing for such a variety of plausible reasons. She might then simply have incinerated that empty ampoule with the other disposable rubbish instead of sounding the alarm in the hope of saving a baby — hardly more than a foetus — at such dire cost to her career.
She knew, as we all do, that some babies who have respiratory difficulty at birth will die suddenly and inexplicably, and that ' the postmortem examinations are therefore' often cursory formalities. Digitalis' could not have been detected in the blood unless it has been specifically looked for, and there would have been no reason to look for it. She would never have been held to blame.
Many more such tragedies will certainly take place, often unperceived by the perpetrator, whose knowledge of English may be rudimentary, or even noticed but glossed over and hidden. Not all nursing staff will have the same moral fibre, personal courage and sense of honour of that staff nurse.
Let us finally recall that we live in a strange world, obsessed by the utopian dreams of social engineers who seem to think that all unpleasantness can be avoided by adequate administrative legislation. We forget that there exists an irreducible, constant minimum proportion of human errors and incorrect decisions in all fields of human activity, quite regardless of motivation or punctilious training and watertight standing orders. Let us, by all means, be ruthless, punitive and even vindictive if a tragedy is caused as the result of self-indulgence or dishonesty. This, however, was clearly a case of unaccountable inadvertence. Let us, therefore, exercise compassion and charity, It could have happened to any of us.
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