To be good, you need to be lucky!

Medical errors causing death, are not that uncommon, and often depend on how Lady Luck was disposed towards you that day.

Even in a developed society like USA with their multiple levels of checks and balances, and the highest risk of litigations, around 7,000 deaths are estimated to occur each year from medicine errors alone; that is, mistakes in giving the right drug in the right dose at the right time and then no adverse reactions to follow.

Mistakes are of course mistakes and human errors can never come down to zero wherever humans are at work, but the way society reacts to errors can be quite interesting.

In a prescription, error that I vividly recall from my residency days 35 years ago at AIIMS, a 35 years old woman with palpitations due to a hyper-active thyroid who was prescribed CIPLAR (propranolol) by my colleague turned up four weeks later feeling quite nauseous and miserable. When we saw the medicines she was carrying, we were shocked to realise that the pharmacist had given her Ciplin (an antibiotic) instead, as her prescription paper had got sullied in the rain.

Luckily she did not come to any permanent harm and recovered promptly once the medicine was corrected.

In another example involving similar names, an elderly patient with chest infection and wheezing was prescribed Ciplin, the antibiotic, but was administered Ciplar by mistake. Within a couple of days, his breathlessness worsened, heart rate and blood pressure fell and he succumbed to his chest infection.

When we look at the two errors described above, we intuitively feel that the second one was much graver, the reason being that it led to death. We are often willing to overlook the first one as just “an error” because the outcome was not so disastrous.

From the nature of mistakes however, they are funnily similar – mistakes in names of similar sounding medicinal names. It is the consequence that seems to make us decide how we apportion blame and punishment.

Philosophers describe “moral judgement” as it is called, by this typical example: imagine a negligent driver jumping a red light at a crossing, but managing to go through without any fatal accident. He will be “judged” to have violated a traffic signal and penalized mildly by the traffic police, if at all caught. If on another fateful day, another negligent driver jumps the same traffic red light and happens to hit a child in a pram, who then dies in hospital, we are likely to cry “murder”! The nature of mistakes is much the same, though the outcomes are vastly different.

The question then is “Do we judge someone right or wrong, or call a person good or evil, by his actions or by the outcome of his actions?”

Mortal luck pervades our daily lives. Remember when you left the gas open in the kitchen last time, or answered the cellphone while driving, that made your car swerve? And nothing happened? Luck could have had it the other way!