NEW YORK -- Several years ago, my daughter lay in a coma after a serious fall. Two nurses came into her hospital room to prepare for a transfusion. One clutched a pouch of blood and the other held my daughter’s medical dossier. The first read aloud from the bag, “Type A blood,” and the other read aloud from the file, “Alexa Holmes, Type A blood.” They then proceeded, following a script, to switch props and roles, the first nurse reading from the file, “Alexa Holmes, Type A blood,” and the second reading from the bag, “Type A blood.”
Why do well-trained professionals, when struggling with a rapidly unfolding emergency, adhere to rules laid down in advance? The principal reason is that in times of crisis people fall into predictable but avoidable errors, largely because of panic. Over time, detailed protocols have evolved for such confusing situations to encourage cool-headedness and minimize the risk of avoidable error.