1. This medication is not supposed to be diluted. There are concentrated formulations to allow those patients that are highly tolerant to the effects of the medication – like a cancer patient might be – to take reasonable amount. For example, a patient that is not usually on this type of pain medication may take 5ml of the normal concentration. A highly tolerant cancer patient – one that needed the 20x stronger strength – would have to take 100ml of the normal concentration to get the pain control they require. The concentrated medication allows the highly tolerant patient to take a reasonable amount – 5ml.
2. As long as there are humans in the system, there will be errors. There are a number of dangerous things that we do that – even with focus – can go wrong with a simple human error. Most drivers remember a time, at some point, where they realized they accidentally ran a stop sign. Search the internet for babies in cars, and you will find hundreds of ‘hits’ where a person accidentally left a baby in the back of a car on a hot summer day, only to realize the error when it was too late. Compared to all of the babies in cars, it is a very very small number, but it demonstrates that humans do err, even with the thing they find most precious. Consider that if a pharmacist is filling 350 prescriptions a day, that is 1750 filled in a five day work week. At a 99.9% accuracy rate, there will still be 2 errors per week. Humans aren’t anywhere near 99.9% accurate, no matter how careful, how highly trained, or how competent they are. You cannot educate perfection or educate away human falliability. Thankfully, most errors do not result in tragic outcomes, as it did with this case. My thoughts are with the boy and his family, with the hopes of a rapid and complete recovery. I hope that his young age helps him recover further than the physicians predict.
3. The human mind tries to balance the consequence of an error with the severity of an error. For example, consider if you accidentally run a stop sign an no one gets hurt. Consider the same error – accidentally running a stop sign – and someone gets killed. It is the same error in both situations – that is, it is the same failure of the human mind – but the consequences are different. That’s why design of processes to assume that these errors will always occur – and to try to capture them before the reach the patient – are key to patient safety.