Table 1

Chronology of a case showing errors and communication failures

Sequence of eventsFailures
A child was a patient in a district general hospital and due to receive chemotherapy under general anaesthetic at a specialist centre. He should have been fasted for 6 hours before the anaesthetic, but was allowed to eat and drink before leaving the district general hospitalFasting error. Communication problem between district general hospital and specialist centre
No beds were available for the patient on the oncology ward so he was admitted to a mixed specialty “outlier” wardLack of organisational resources (that is, beds for specialised treatments). Patient placed in a environment lacking oncology expertise
The patient’s notes were lost and not available to ward staff on admissionLoss of patient information
The patient was due to receive intravenous vincristine, to be administered by a specialist oncology nurse on the ward, and intrathecal (spinal) methotrexate, to be administered in the operating theatre by an oncology specialist registrar. No oncology nurse specialist was available on the wardCommunication failure between oncology department and outlier ward. Absence of policy and resources to deal with the demands placed on the system by outlier wards, including shortage of specialist staff
Vincristine and methotrexate were transported together to the ward by a housekeeper instead of being kept separate at all timesDrug delivery error due to non-compliance with hospital policy, which was that the drugs must be kept separate at all times. Communication error. Outlier wards were not aware of this policy
When the fasting error was discovered, the chemotherapy procedure was postponed from the morning to the afternoon list. The doctor who had been due to administer the intrathecal drug had booked the afternoon off and assumed that another doctor in charge of the wards that day would take over. No formal face-to-face handover was carried out between the two doctorsCommunication failure. Poor handover of task responsibilities. Inappropriate task delegation
The patient arrived in the anaesthetic room and the oncology senior registrar was called to administer the chemotherapy. However, the doctor was unable to leave his ward and assured the anaesthetist that he should go ahead as this was a straightforward procedure. The oncology senior registrar was not aware that both drugs had been delivered to theatre. The anaesthetist had the expertise to administer drugs intrathecally but had never administered chemotherapy. He injected the methotrexate intravenously and the vincristine into the patient’s spine. Intrathecal injection of vincristine is almost invariably fatal, and the patient died 5 days laterInadequate protocols regulating the administration of high toxicity of drugs. Goal conflict between ward and theatre duties. Poor practice of expecting the doctor to be in two places at the same time. Situational awareness error. Inappropriate task delegation and lack of training. Poor practice to allow chemotherapy drugs to be administered by someone with no oncology experience. Drug administration error