27 September 2011


My heart sank and I swallowed nervously. I had just finished administering a vaccine for the second time ever, and the syringe's plunger felt strange as I finished pushing it in. It hit me. I had forgotten to check the vaccine for air bubbles, and I had injected a bit of air into my patient's left deltoid. I pictured him climbing into bed that night and dying of an air embolism, a cruel fate brought on by a vaccine that was supposed to protect from harm.

I tried to look calm and found an attending physician, who assured me that everything was fine. The amount of air in vaccines is miniscule, and in fact, having a bit of air in the syringe often helps an intramuscular injection. No harm done. But I was still shaken. Just like that, I had skipped a step that I had believed at the time to be critical.

The experience convinced me of just how easy it is to commit a medical error.

Even a simple procedure like administering a vaccine involves a number of important sequential steps. The sharps disposal container needs to be placed within arm's reach before the needle's cap is removed. The medical chart needs to be double-checked to ensure that the correct vaccination is being given. The injection site needs to be disinfected properly. Inevitably, even the best practitioners mess up a step. Medical errors are a tremendous problem, responsible for 48,000 to 98,000 deaths per year.

There is a growing movement to use checklists when carrying out medical procedures, just as pilots do when they fly. My favorite medical writer, Prof. Atul Gawande, wrote a fascinating article in the New Yorker on the subject, which I encourage you to read for free. Yes, individuals commit errors, yet the systems they work in can reduce the likelihood of those errors. For example, anesthesiology equipment wasn't standardized in the past, and turning a knob to the right would release more anesthetic on some machines and release less anesthetic on others. Now the equipment is consistent at every hospital in the country, avoiding needless deaths.

The fruits of prevention efforts are masked. When a hospital implements a labeling system to avoid wrong-side surgeries, patients who are saved won't know how narrowly they avoided catastrophe. It's not very obvious when the system succeeds, only when it fails. But even if prevention isn't sexy, we need to still try. Avoiding medical errors is inexpensive, it saves lives, and it is the right thing to do. For my part, I'm writing up a checklist for myself on how to administer vaccines properly.

Photo reproduced with permission via Creative Commons license. Author: @alviseni