The injection of chlorhexidine instead of anaesthetic into Grace Wang’s spinal canal is a tragedy for Grace, her family and the health practitioners involved. This case is perhaps made more concerning because this mistake allegedly occurred as a result of the use of an outdated method of drawing up drugs.  The very reason why these procedures were altered in the first place was to avoid a preventable accident like this from occurring again, because it has happened before. Because it has happened before, the healthcare sector and the government worked together to redesign our system of reporting errors to promote transparency, and to offer a way of identifying systems failures that could allow a redesign of the system to ensure that policies, training, the environment and even the equipment could be altered to ensure staff were working in a system that made it very hard for them to make mistakes.

Lucian Leape argues that all of this helps but that the area in which we need further improvement is in the development of the culture of teamwork — an area in which doctors and nurses have not traditionally been well trained. In the case of Grace Wang, both the chlorhexidine and the anaesthetic were drawn up into syringes by someone other than the doctor who administered the drug. The drugs then became unidentifiable to the anaesthetist. Best practice requires that the drug is drawn up directly from the vial or ampoule into the syringe by the person who is to administer it. So how and why was this outdated procedure able to still be performed without someone in the system catching it? Leape argues that there are several reasons, but one that stands out is the failure of the team. He says that our educational systems, in medicine and nursing, have emphasised individual performance. He argues that in order to improve our systems we must improve our teamwork. He says good teamwork requires it to be multidisciplinary with a clear focus, a levelling of the hierarchy, mutual respect and strong leadership – oh yes, the patient must also be included as part of the team. For example, a patient who knows exactly what medications have been prescribed and also feels comfortable communicating with doctors and nurses might well notice when a wrong medication is about to be given and intercept to prevent the error.

Leape argues that the culture amongst the various health disciplines and organisational change is required to facilitate improved teamwork amongst health professionals. We have already seen changes in the law that reflect the equal status of health professionals. Where once nurses would be either scapegoated for the mistakes of the doctor or the doctor held responsible for the actions of the nurse, now both professions are held equally responsible for their individual actions. What changes should we reasonably expect from our healthcare structures and organisations to further assist the development of teams amongst health professionals?