A Real Eye Opener!!!


Donna Chenoweth
:pleasantry:Everyone at one time or another - “It's the same as it has always been.”

Taking that last one, I'd like to build on it a bit. Sure, it is the same as it has always been. At least until it is different. We cannot rely on any system to be perpetually static and unchanging. Routine without awareness of the possibility of the unexpected occurring is foolhardy behavior. In the book “Deep Survival”, Laurence Gonzales tells how some people go around acting like they are the heroes of their own action movies. That is a dangerous mindset to have.

A Colorado woman named Mareena Silver, or Silva depending on the news reports at the time this article was written, took a drug called methotrexate that was prescribed for someone else. Here is an incredible example of mistakes both in the event and the reporting of it. Apparently a woman took a drug prescribed for another woman with a similar name. Even the major news outlets report different names. One report indicates that Mareena Silver took a drug prescribed for Maria Silva. Another report indicates Mareena Silva took a drug for another woman with the same last name. Consistent in the reports is that the name on the bottle did not match the name of the woman who took the pill. Even the news outlets can't get the story right.

Regardless of the details of the name or spelling, news stories are repeating the line that it was the pharmacist who gave her the wrong pill. Actually, according to news stories, Mareena Silver/Silva had taken a pill from a prescription bottle that she thought was her prescription but wasn't. The major issue is that Mareena is pregnant and methotrexate is used to treat severe psoriasis and cancer, and it is sometimes used to abort pregnancy. It wasn't reported that the pharmacist put the wrong pills in the bottle; it was reported that Mareena had the wrong prescription altogether. It appears she didn't fully inspect the refilled prescription before taking it. It appears she trusted in a system to remain as it had before.

The chance of error being caused by anyone or anything from any system is not only likely, it is probable. That is why we must promote the “self” in self-defense. Self-defense goes way beyond learning to fight or shoot; it includes learning to be diligent about reading prescription bottles and being able to fully recognize the pills in the bottle. I used to feel uneasy with each bottle of liquid medicine that was compounded by a pharmacist for our dog Lucy. I couldn't be certain of the concentration of the drug or if the correct drug was dissolved in the water. I can be much more certain about pills and capsules.

I've been given the wrong pills before at a pharmacy. I caught the mistake immediately because I don't put full trust into a system. The fact of the mistake actually helps to set me apart from the other customers for more critical certainty from the employees who remember the incident. If I'm prescribed something, I can look up the exact pill or capsule online and see a picture of it from all of the manufacturers that make it. Pharmacies routinely get the same drugs from different manufacturers, and the drug's size, shape and color may change. I look on the bottle for who made it and look at a picture of what it should look like. I also confirm changes with the pharmacist. I always check to be sure it is my name, address and phone number on the label as well as the correct drug name and strength.

This isn't an article just about checking your prescribed pills. It is about taking a critical look at all of the systems we routinely rely on. That is just one thing of many where we have to take responsibility for being certain of things ourselves. Do not assume, do not trust, do not suppose, do not guess, do not hope—be certain yourself. It is mind boggling the level of trust we put into systems. The whole reason we have the word “redundancy” is because systems fail. It is why we have more than one lock on a door, it is why we have an emergency brake on the car, it is why there is a flashlight in the drawer, it is why I carry a gun. NASA is all about redundancy, and astronauts have still perished.

I would like to present an exercise for everyone reading this to do this week. Take a critical look at all of the systems you rely on too much without scrutiny. How many of those systems do you have any redundancy plans in place in case of failure? How many of the systems do you regularly confirm they are remaining operational and consistent? Write it down. At the end of the week, you will have a list of things that need your critical attention. Making changes or simply recognizing failure potentials of the systems we routinely rely on may some day save a life. The second part of that last sentence is really important—recognizing failure potentials of systems. The brakes on your car are an example. The redundancies are a dual master cylinder that will retain some braking power if the front or back brakes fail. If there is catastrophic failure of the hydraulics, the emergency brake itself is a redundant braking system.

Take a look around you at the systems you trust and their failure potentials. Even just an awareness of these things puts you at an advantage.

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