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Another wee story about mistakes

Toilet roll on floor. Copyright www.istockphoto.com ID 000016134786

Inspired by the children's book 'Father Christmas needs a wee' Dom Furniss of UCL has been telling us festive, but true, stories about his friends dashes to the loo. So far we've seen how being short of knowledge can lead to messy problems. Read on to learn more about avoiding nasty accidents, this time due to slips.

Lifting the lid on another problem

Stacey was heading to the station to go home after christmas drinks with her friends. She started picking up the pace a little as she felt the need to go to the toilet. She should have gone before she left. Too late now!

Trying to remain composed she broke into a bit of a jog. It wasn't that unusual for people to be rushing for a train, and she wasn't too far from the station now. The fact that she was in a business suit and heels didn't help. The urgency was getting worse but the station was in sight. She was worried. Would she make it? The pee was coming whether she was in the right place or not!

She made it into the station but knew that it was going to be close. She didn't want to think about getting there just in case this somehow triggered her muscles to relax. She went down the stairs to the ladies'. Was she going to make it? She was through the barriers. She couldn't hold it for much longer. She made it to a cubicle - it was going to come at any moment! She opened the cubicle door - disaster wasn't quite there just yet. She got inside - it was so, so, so close. She slammed the door behind her - was she really going to make it?? She pulled down her knickers, sat on the loo, and relllllaaaaaxxxxxxeeedd... But no! There was pee flying everywhere! She looked down and saw that she hadn't lifted the lid off of the loo! The amazing sense of relief was immediately replaced with intense panic as she wet herself knowing that she still had the rest of the commute home. How was she going to manage this one?

Slippery slips

Stacey made what is known as a slip-based error. Other examples of everyday slip-based errors include dipping your paintbrush into your tea rather than your paint pot, leaving your car lights on so you get a flat battery, and pouring orange juice into your cereal rather than a bowl. They are not due to a lack of knowledge: Stacey did know you can't use a toilet with the lid down after all. Instead, they typically happen due to lapses of memory and attention. Stacey just didn't notice the seat lid was down. If she had she would have done something about it. When we are thinking about something else (and being stressed probably doesn't help) we can easily miss otherwise really obvious things like a closed toilet lid. That means you don't stop slip-based problems happening again by giving people missing knowledge. Telling Stacy about the need to lift the loo lid misses the target as badly as she did. You can, however, redesign the situation to reduce the chances of it happening. Get rid of the lids on station loos, for example.

If she had noticed she would have done something about it.

Toilet slips are embarrassing but it's not a matter of life or death. A slip in a hospital could kill someone, though. Take an infusion pump. They are drug delivery devices - a nurse tells it how much drug to infuse into the patient and for how long. It then just gets on with it. A worry is that a nurse making a slip error might accidentally type in the wrong dose into a pump. With good design, the pump can help catch this kind of slip. For example, some now use smart drug libraries that know what doses make sense. If one of the numbers the nurse enters is grossly outside the expected range, it won't start the infusion and instead alert the nurse.

Another problem that can happen with an infusion pump is a free flow incident. It's where the drug bag just empties straight into the patient due to gravity rather than being infused gradually - even machines can have the equivalent of a human wee accident! It might happen if the nurse forgot to close the clamp that stops the flow when the pump is being disconnected, for example. Some infusion pumps now have mechanisms that automatically cut the flow when that happens. Again good design can guard against these kinds of slips everyone makes occasionally.

The book, 'Father Christmas needs a wee', aimed to use pee problems to teach kids to count. Hopefully, our toilet humour has taught you something about patient safety, design and human error.