Normal accident

I'm interested in drugs:

• as a tax-payer because of the mad amount of money given to MegaPharm Inc. to achieve a marginal benefit for an unfortunate sufferer of a rare disease [prev Morquio; Orkambi]
• as a philologist bemused by the truly daft and eye-crossing names which the developers choose to give their products: infliximab  has been around a long time now and it kinda of trips off the tongue but some of the others just give me a stutterimabitis; daclizumab, solanezumab and aducanumab and adalimumab; . . . but tositumomab? that might stick especially if nausea is a likely side-effect - Toss ye tum, geddit?
• as a carer lurrying a handful of coloured pills every Sunday night into Pat the Salt my mildly demented father-in-law. They look a lot like sweets, luckily there are no small children to mistake the drugs for something to eat.

As well as teaching human physiology to Pharmacy Technician PT students, who are working towards a Level 6 Certificate,  I share an office with The Pharmacist at one of the local chemists, who works part time teaching at The Institute. She is very discrete - it goes with the profession - but I occasionally get to hear [strictly anonymised] tales of 'mistakes were made'. We are in the process of making up a Level 7 PT Diploma and one of the courses to be offered is called something like error checking in the pharmacy.

As I mentioned in a related matter, a third of all deaths in the US [or any other country where they have doctors] are the result of medical error. I know of one non-fatal prescription error case. Father of a pal of mine elected to have back surgery, which didn't go so well: he finished up with persistent tooth-grinding debilitating pain. The meds to combat this were required so often that his practice team fitted him up with a catheter at his waist, so that he could give himself a jolt of pain-killer when he felt he needed it. Once a month the old chap had to travel up from the country to fill up the reservoir at the teaching hospital which had bungled his surgery. It took him all day with the travel and the waiting. One month, finally sorted, he set off towards the train station, felt a twinge as he crossed the hospital car-park, pushed the admin button and promptly collapsed. The doctor had mis-written his script so he got 50x the required dosage. If this is going to happen, just outside the doors of A&E is the best place . . . so he survived.

That was probably culpable negligence. Normal Accidents are when several small-small errors and misunderstandings, trivial and recoverable in themselves, accumulate towards a disaster. A small example might be when the doctor's hand-writing is so illegible that the local pharmacist wings it when interpreting the scrawl and gets the dose or the drug wrong. You can't ring up the bloody doctor for every script and of course the god-walking-this-earth doctor couldn't be prevailed upon to write clearly. Maybe this is dying away in the electronic world. Maybe that is not a good idea: if you have to work, even a little, then you'll think a little before you dash off the script.
These things are pervasive enough that Charles Perrow wrote a book about them in 1984: Normal Accidents: Living with High-Risk Technologies. This starts off with an analysis of the almost disaster of the Three Mile Island nuclear reactor accident. I was there! Or rather 600km downwind shortly after I arrived in Boston for my PhD in 1979.  It is an interesting case study where a combination of equipment malfunctions, design-related problems and worker errors conspired to cause a partial melt-down.

Network Rail in the UK have put out a handy set of short training films, reconstructing events where something has gone wrong. Here's one where the three men involved in a SPAD - signal passed at danger - speak to camera regretting their actions, inactions and poor communication skills. I think it would be just bonzer to make a similar film with our PT students acting out a prescription error in our pretend-pharmacy lab at The Institute. And lest you think that Lost in Translation is always tragic here's one that's funny.