Poor communication costs a life
If you think bad procedures can’t be deadly, a story on ABC TV’s 7:30 Report on 5 May 2004 may change your mind.
Guido Squillaci, who was being treated for Burkitts lymphoma in a Sydney hospital, died after the drug Vincristine was injected into his spine instead of into a vein.
Vincristine destroys the nervous system when given this way. Mr Squillaci, 28, died four weeks later.
How could it happen? We spotted three common communication errors:
Poor instructions
Although there were instructions for giving the drug, the radiology staff don’t seem to have understood them, assuming they read them in the first place. We’ve found written instructions don’t work when they:
- are worded in a confusing or ambiguous way
- don’t directly address the person who has to follow them
- are written from the point of view of the writer rather than the person who has to follow them
- aren’t supported by training to give the instructions context.
Poor design
The printed label on the drug wasn’t complete—instead of saying “Fatal if given intrathecally” it only read “Fatal if give”. People can’t read an instruction if it isn’t there. Better design would have helped.
Illegible type
Even if the text had been there it would have been difficult to read. The type on the label was in CAPITALS—much harder to read than text in lower case—and, at about 2mm high, too small. In the “darkened room” in which Mr Squillaci was given the fatal injection, the text was illegible.
The hospital has since revised its procedures.
Recently noted
Burns highlight system’s failure
A $189,000 (AUD) fine has highlighted need for effective systems to ensure work methods are safe, according to WorkCover New South Wales.
The New South Wales Industrial Relations Commissions Court fined Port Kembla Copper Pty Ltd after two workers were seriously burned in similar incidents less than three months apart.
In sentencing the company Justice Haylen said the two incidents emphasised that systems needed to be reinforced and vigilantly policed to be effective.
“Employers must ensure that their workers have a clear understanding of the required safe work methods for performing tasks”, WorkCover Chief Executive Officer, Jon Blackwell, said.