0722 Report of A Medical Error Event

I read a Taiwanese news which is about a medication error yesterday. The news mentioned that a nurse gave penicillin to a patient who is allergic to it, and this mistake caused the patient fall into a coma. After the news was reported, most people start to talk about problems of medical system. Some experts also pointed out two flaws in the medical system.

First flaw is manpower shortage of nurses. According to the survey, the average working hours per week of nurses are 42 hours, and overtime is a common situation for most nurses in small hospitals. The ratio of patient to nurse is 10, even as high as 20 in the night. The long working hours and heavy work let nurses make mistakes easily.

In addition, the medical staff do not exactly follow standard operation procedure (SOP). Standard operation procedure is an important system which can avoid the mistakes and direct everything on the right way. I do believe that before a nurse gives medicines to a patient, the nurse has to check medicines and the patient more than once. Like train drivers, nurses have to confirm what they do by speeches and gestures, because action with voice and body language can be more aware than action by only thought.If the nurse had followed the standard operation procedure exactly, the mistake would not have happened.

I hope every serious mistake can be a lesson and will not happen again. Once experts find out flaws, the government or authority has to fix flaws immediately, or mistakes are always be mistakes, not a cornerstone of progress.