Standardisation and harmonisation are two of the most urgent issues we have to tackle. Imagine if you have to learn each new system wherever you go or even whenever a new senior doctor is on the ward. This introduces massive risk.
- Mary Dixon-Woods
In November 2004, Mary McClinton was admitted to Virginia Mason Medical Center in Seattle, USA, to receive treatment for a brain aneurysm, a potentially serious swelling in a blood vessel. What followed was a tragedy, made worse by the fact that it was entirely preventable.
McClinton was mistakenly injected with the antiseptic chlorhexidine. It happened, the hospital says, because of “confusion over the three identical stainless steel bowls in the procedure room containing clear liquids — chlorhexidine, contrast dye and saline solution”. Doctors tried amputating one of her legs to save her life, but the damage to her organs was too great: McClinton died 19 days later.
Nine years on, an almost identical accident occurred at Doncaster Royal Infirmary in the UK. Here, the patient, ‘Gina’, survived, but only after having her leg amputated.
Professor Mary Dixon-Woods is one of Cambridge’s newest recruits, and she is on a mission: to improve patient safety in the National Health Service and in healthcare worldwide. She has recently taken up the role as RAND Professor of Health Services Research, having moved here from the University of Leicester.
It is, she admits, going to be a challenge. Many different policies and approaches have been tried to date, but few with widespread success, and often with unintended consequences.
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Image:Intravenous drip
Credit: Toshiyuki Imai
Reproduced courtesy of the University of Cambridge
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