There’s been a lot of talk about working hours on this blog recently, as well as the risk that tired doctors pose to themselves and patients. That got me thinking about silly things I have done without thinking when I was exhausted. These all happened either at the end of a long call, or when I was post-call.
- Been confused about not finding any good veins for an IV on a patient. Then the patient asked, “Aren’t you planning to use the tourniquet?”
- Delivered Mrs Smith instead of Mr Smith to radiology for imaging studies (and then had to walk all the way back with her and return with the correct patient).
- Used Vitamin B instead of Heparin to heparinise a syringe. The bottles were next to each other in the fridge and both had dark green tops. Fortunately, I noticed the error before doing anything stupid like breaking the blood-gas machine. (Which costs something crazy like ZAR150,000 to replace if broken.)
- Called a Professor “uncle” – that was really embarrassing!
- Walked into the OR with theater scrubs, but without a cap or overshoes. The scrub nurse was NOT impressed.
- Sent blood for a cross-match in a biochemistry vacutainer instead of and EDTA tube.
- Made really silly errors in exams.
- Turned onto the wrong side of the road (luckily an empty road).
We all joke about these, because they are funny, and no harm occurred. But not all errors are harmless.
I also know that I am not the only one who does things like these when exhausted. I have a friend who, in his exhaustion, sent bloods with the pneumatic tube system… without putting it in a capsule first. The tube operators were very unhappy, not least because the shattered containers were an occupational hazard to them.
Who are we to assume that qualified physicians, with much bigger responsibilities, are not likely to make mistakes when working too-long hours?
Just a thought.