Texas Tech University Health Sciences Center
Caution and Consideration: Preventing Error in Health Care

Caution and Consideration: Preventing Error in Health Care

A friend of mine made a humorous post recently on Facebook about how he had mixed up salt and sugar in preparing Christmas cookies.  This led to an unpleasant surprise and some good-natured ribbing from other Facebook friends when he made this confession.  Fortunately, it was not of major significance.

But, it caused me to think about a case in which infants died as the result of salt and sugar being mixed up in formula preparation. The case occurred during the early 1960s in New York State and received a lot of attention.  You can read about it on the Web if you are interested.  Now at this time of year, some might consider it poor timing on my part to bring up such a tragic occurrence.  But, I do it for a reason. It underscores the criticality of paying attention to what we are doing.

When I was a hospital administrator, surveyors  from the Joint Commission came to survey our hospital every three years.  We had received a heads up that a particular surveyor’s special interest was ensuring that the salt-and-sugar mix-up never occurred again.  His idea to prevent this, which was a good one, was to label both the containers and the lids according to which product each container held. For example, if you had a large container of salt and a large container of sugar, the container itself, as well as the corresponding lid, should be labeled.  He believed that in the rush of preparing food, it was too easy to put the salt lid on the sugar container or vice versa. He was right, of course.

When it came time to inspect the kitchen, he went straight to the salt and sugar containers. He looked at them and saw that on both the lid and container were clearly labeled, he just grinned and said, "So, you have heard of me, eh?"  I pled the fifth and just grinned back at him.  I never forgot the lesson.

Again, the point of this article, in such a happy time of the year, is that we are in a business where people put a great deal trust in us to do things right.  We consider it both an honor and responsibility to do these things consciously and to the best of our ability.  We enjoy the public's trust and we want to keep it. Enjoy your holiday!

Brent D. Magers, FACHE, FHFMA, CMPE