A series of unfortunate events

Mr F nearly died this afternoon.
It could have been prevented.
At least four people did not noticed the one thing, that is easily correctible, that led to his cardiac arrest.
I was one of them.


There are two learning points from this:
(1) LOOK at ALL results (even if someone else says they have already done it)
- for instance in this case, the gentleman had acute renal failure. All I overheard was his sky-high creatinine level. His potassium level was not mentioned, but as I had just joined the ward round, I assumed that it must be alright as no mention of it was made. The team moved on and I started to manage him, as one would with acute renal failure: catheter, bloods, fluids, blood gas.
- As the blood gas result came from the machine I glanced at the top figure, noted he was acidotic and went to join the ward round, as the consultant was on his own at this point. I showed the result to the consultant, who also noted that Mr X was acidotic, but felt it would correct as his renal failure was managed. Neither of us noted the potassium level on the blood gas result.

(2) Put EVERYTHING down in writing
- I had not noticed the potassium on the blood gas measurement. But I did stick the results in the patient's notes, and made a note next to it that it had been reviewed by the consultant who decided not to change management at this point. The patient did not benefit from this. But it means that I will not get the blame for this.

That does not stop me blaming myself.