“Because I was looking for it”, says Sherlock Holmes, half-patiently, in the middle of an intense fight with Lord Blackwood. He was referring to the poison-tipped fine-glass needle.
While this story had a happy ending, looking for what you want need not necessarily be the perfect way ahead. The neurosurgical team at Tufts had a tough lesson to learn.
They found what they were looking for and pretty much shut out everything else.
While the neurosurgeon had asked for omnipaque, the pharmacist had informed the nurse about the unavailability of omnipaque, and had instead supplied them with two bottles of MD-76, which clearly was contraindicated for spinal infusion. The serious warning saying “NOT FOR SPINAL INJECTION” had slipped through multiple barriers not because nobody was looking for it. Rather because everyone was looking at the positive signs such as being handed over by a trustworthy pharmacist or nurse.
View original post 200 more words