Tuesday, November 9, 2010


I ended up going with the chili plant for my friend's birthday, not that it was even one of the options... There's no time these days to construct the perfect gift, to put the amount of thought into things that I'd like. I'm getting used to the idea that rather than organic homemade muesli bars, like the ones I'd imagined, I'll be throwing together packet cakes for my family, if I even have time to have a family.

How on earth do you reconcile the desire to excel in your work, to be a wonderful partner, a best friend, a lover, a daughter, sister, citizen, musician, baker, person who spreads happiness? Who can tell a joke, bring a smile to a room, heal the sick, or at least not make them worse?

I'm a long way from any of those things.

Today I made a medication error. Actually, the error was made yesterday, but I found it today. I accidentally gave a patient a drug that they did not need, that could have harmed them. All drugs have side effects. I accidentally gave a small dose of mirtazapine, a commonly used antidepressant.

It happened like this. The nurse looking after these two patients was pushy and persistent. I had stated in the morning meeting that we would start a low dose antidepressant at night for our psychotic and demented 75 year old patient. She had been keeping the whole ward up on a nightly basis and was requiring sedation and mechanical restraints in the form of a Posey jacket to keep her from wandering the ward and disturbing the other patients.

Anyway, the nurse was chasing me to chart the medication. I said that I would do it when I recharted all that patient's medications; I didn't want to make a mistake. Later that day she came up to me and put the medications chart under my nose and said 'Can you please do it now!'

This is in no way the fault of the nurse - she was pushy, sure, but lots of people are. She was just doing her job, and being herself. The issue of nurse and doctor dynamics is neither here nor there, although I'll address it at some stage.

The point is that I wrote the prescription in the chart, and gave it back to the nurse. Today I was reviewing the medications, and saw that the wrong patient had received mirtazapine.

I felt hot and cold. Sure, the patient is fine, absolutely fine. As medical errors go, this one is minor and almost consequence-free. But it's a mistake, it shouldn't happen, and it must never happen again.

As my consultant said - this is something to learn from. At least it won't ever happen again.

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