I took some time off over the holidays, which meant, among other things, irregular hours and lots of night time television. A show that has captured my attention is one on National Geographic Channel called Brain Games.
By now most of you know that I have become fascinated by the notion of the limits of human diligence. On one of these programs, I watched as a group of people who witnessed a theft describe what they saw. What was interesting was (a) how little of the detail around them they actually noticed and (b) how easy it was for someone to plant the notion of things that weren't there or hadn't occurred.
Statistics in the show were interesting. An intelligent adult can only keep track of 5 or so things at a time, if they really concentrate. Even then, we don't really 'multi-task"; we actually switch our attention from one thing to another. Now think about all the balls we have to keep in the air when we work in a pharmacy. Is it any wonder that we occasionally make a mistake?
As I listened to this show I was reminded of a technician who once told me that they could keep 15 or 20 things going on simultaneously within a hood and never lose track of any of them. The information in this show strongly suggested that to be impossible. Indeed, it sounds like trying to manage that many projects at one time seriously increases the risk of error.
Yet, when we look at sterile compounding facilities, we tend to prize, even promote individuals who work this way.
Is it any wonder we haven't moved the needle on medication safety in ten years?
I am reminded that those high-reliability industries where the cost of human error may not be a single human life, but thousands, or the desolation of our ecosystem, all have in common that they have studied, and embraced the notion of severe limits of human diligence, and have built systems, and technologies to accept that the errors will occur, and to catch them and prevent them from becoming harm.
Maybe we need to do the same things for pharmacy.
What do you think?
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