Accidents happen: Part Two

Did I say “accidents happen” the other day??

What was I thinking?!

It’s like saying its q___t at work; never say the Q word!! It invites chaos and busyness and problem scripts one after another. But I said accidents happen, and so they did! Fate heard me, even though I don’t really believe in fate…oops, is that another invitation to the world to punish me?? Well punish is a bit dramatic, but you know what I mean.

So I’ve been recovering from accidents and errors ever since I wrote about accidents!! It wasn’t enough that I had my first ever minor car accident last Friday. On Wednesday, I had to go and fall down the stairs!! Like a really idiot!

I think it was sleep stupor, but to be honest I don’t really know. It was morning so sleep stupor could cover it; not much of a morning person, me. I took one step down leading with my right foot, another step down now with my left foot, another with my right and then I just slipped off the far edge of the next step with my left foot and I was gone. Our stairs go halfway straight down, turn 180 degrees then the other halfway straight down. Pretty standard. I slipped on almost the last stair before the turn. It might have to do with the stairs being shaped as wedges for the turn and I hit the tiny point of the wedge. I don’t really know how but somehow my left heel hit close to the edge of the stair and just slipped right out from under me and slipped over stair after stair after stair with no grip on any of them. My left leg was a useless slippery pointy thing sticking out in front of me causing nothing but trouble!!!


Brain kicking into overdrive trying to figure out what to do, hoping to hit the wall at the bottom of the first half of the steps, grabbing the railing by instinct rather than thought, left leg useless sticking straight out front and can’t get a foot hold anywhere, getting half a grip on one stair after another but slipping over each and every one, poor right leg tucked underneath getting banged and scraped stair after stair after stair!!


Luckily, and there is always an aspect of luck with me somehow, I was trailing my hand down the banister and managed to grab it! And even though my grasp slipped down the banister, it got caught on the post halfway down at the corner and I managed somehow to haul myself to a stop. I’ve seriously wrenched my neck and back and arm because of stopping myself but at least I didn’t go head over heels or something worse. And at least my hand was in contact with the banister when I fell; usually I don’t hold on at all! So it could have been much worse. Apparently its a workplace OH&S recommendation to have 3 points of contact with stairs at all times: 2 feet and 1 hand, or 1 foot and 2 hands if you are that person who just has to push the envelope! So maybe I need to put up some OH&S posters in my stairwell!

Panic as several steps went by and I missed the wall at the end, turning instead to start going down the next flight! Finally gripping the railing at the post as I slid to it and holding on for grim death!! Or is it life? Either way, I managed to stop on that poor banged up left hip with my useless left leg still sticking out in front, and the even more useless right leg underneath and my arm twisted backwards at some weird angle. So by the time my hand found a hold on the midway post, I was through the corner and heading down the next straight with my right leg tucked well under me getting cheese grated on each and every step where the carpet is bare and the strings are coming through. Basically I got a combination of carpet burn and grating right down my shin and a good few bumps on my left hip, which is swelling up nicely. I was feeling pretty shabby!!

So I was pretty stoked to have come to a stop, even if it was at the cost of the whole left side of my torso and arm. But how to get up?? I’m not a little thing, as most of you probably know. And unable to engage to use of either leg and one arm and side made getting up some kind of origami exercise! I actually can’t tell you how I got up, but there were a couple of bad moments where I started to slide again. But here I am to tell the tale!

So I grabbed on for dear life and managed to stop my fall. There was a moment of real horror thinking that the post might let go; I definitely felt it give. But when I went back afterwards it was as solid as ever. But as it turns out 120kg dangling by one arm is not only a threat to the wooden stair railing but to the muscles and soft tissue behind my shoulder blade. OUCH! Before too long I couldn’t turn my head to the left more than 20 degrees, behind my shoulder blade was singing and I was rapidly becoming frozen stiff. So a trip to the physio to get ironed out.

To look at you can’t even tell I’ve had an accident. Well not until I covered the grazes along my shin with white dressings that is, they kind of stand out on my tan! Not intentional but there you go. It saves me feeling like an attention seeker telling people about my accident; the bandages seek your attention on my behalf!! Is that the same thing?

Its amazing the pain and irritation such superficial scrapes create. Bed sheets, leggings, any clothing just rubs so I headed down to the pharmacy for some dressings so I can at least be a bit more comfortable. Now at least the stinging doesn’t keep getting set off again. But stretching the skin by moving it any way including walking is still aggravating. So here we are, another accident. What to make of this one? I really don’t know what went wrong so that I can avoid it again. Just one of those things? Or I should take more care?

So that was my fall. I thought that was enough, how about you?

But no. I get to work and start my usual Thursday; you know, all the packs and stuff that I wrote about recently. Then my boss brings one of the packs to me and says it has been brought back to the pharmacy over an error! That shoots straight through the heart. Especially right on the heels of having experienced a dispensing error and making (possibly) a big deal about it. As it turns out I hadn’t seen that there were 2 loratadine (you know, Claratyne the anti-histamine) tablets instead of one in Tuesday morning. It’s a robot error, but my job is to pick up that type of error, and I didn’t.

I could justify my omission by saying that its not that serious an error; in all likeliness there would be no side effects as loratadine generally has no more side effects than placebo (sugar pill). But the point is that I missed the error.

I could justify it by saying that the patient hadn’t taken it yet so it wasn’t so bad.

I could also justify the error with the conversations I’ve regularly had with other pharmacists checking packs discussing how extra tablets in packs is the hardest error to pick up, compared to other errors: broken tablets, missing tablets, wrong tablets. But I still missed the error. Not good. But it has made me further reconsider my response to the dispensing error that happened to me.

But wait, there’s more!! Unfortunately.

This, I suppose, is what happens when you only work twice a week. Short of them texting you about issues on your days off (it happens!) they save them up for next time you come in!

So, it seems that I dispensed a patient’s 500mg Epilim (valproate) correctly, then attached the labels to 200mg tablets. THIS is a problem. This is a big problem. I don’t know why the patient was taking Epilim but irrespective, taking this error over weeks to months WOULD have resulted in a relapse had the patient taken it: a relapse of epilepsy resulting in seizures, a relapse of bipolar resulting in depression, mania or suicide or worse. As someone who takes Epilim and dreads the probably inevitable day that I relapse, I can totally empathise with the patient in this scenario, as well as my position as pharmacist!!

I could justify this error by…nope, nothing!! I should have scanned the medication against the dispensing; this would have shown the error. I should have compared the original script to the box of tablets to reconcile the strength; this would have shown the error. I could have reviewed the history, but that’s an extra step. All I needed to do was the 2 steps mentioned; that would’ve prevented the error. Luckily the patient identified the error, brought the medication back and no harm, no foul.

Sound familiar?? My high horse is sinking through quicksand and I’m about to go down with it, unless I jump off and acknowledge that I just made an error as significant as that other pharmacist, and how do I want to be treated over this? What lessons do I need to learn? How would I feel about being reported to the pharmacy board? My boss knows, so that aspect can’t get worse, but he was very good about it actually.

Can I console myself with the errors that I did pick up today? 5 missing doses of magnesium in one pack, 2 missing dose of metformin (for diabetes) in another, a broken Panadol tablet making an underdose, a broken clonazepam tablet (for seizures or spasms) underdose, double the Efexor (antidepressant) dose in one slot, a random thyroxine (for underactive thyroid) tablet found in a pack where the patient doesn’t take that medication, and more. Does it make up for letting a more severe error pass through to the keeper? In short, no.

But it does make you think. Here I am, on a squared playing field, accepting that human error exists but there are systems to obey to minimise it, and ignoring the systems is just not on!

Canberra Day Thirty One

[Tuesday 11th October, 2016]

Well I’m just home from a horrible experience! This is a first for Canberra, and its not Canberra’s fault at all. I thought it would be fun to go to the walk-in bird aviary, after all I love birds, and the promo photos of kids feeding birds in a large aviary looked lovely. But no, ick, awful!! I should have flushed my $12 down the toilet instead; it would have been better spent as far as myself is concerned. I have never seen so many inbred and disgusting looking birds! Have you seen the pigeons in the city? They’re meant to be grey with iridescent green and purple highlights but instead some are white, some are brown, some are black and white, most of them are patchy, and pretty awful and scummy to look at. That’s what this was like! Red-rumped parrots in weird white and yellow colours, rainbow lorikeets crossed with musk lorikeets, olive based colours on rainbow lorikeets, scaly breasted lorikeets crossed with musk lorikeets, olive based scaly breasted lorikeet…it just looked terrible to me! As far as I know this sort of thing only results from mutations and cross breeding. I asked some more more experienced birders online afterwards and they say some inter-breeding could be accidental amongst parrots who have the highest occurrence of inter-breeding compared to other types of birds (but would be weeded out by natural selection in the wild), but some would have to be intentional cross breeding to bring about a new species; this new species should be unable to breed but that isn’t always the case. And some are accidental mutations of colour genes during breeding. So obviously the aviary is a melting pot for all kinds of mix ups!! Not attractive, well not to me anyway. Maybe other people enjoy it. Maybe I’m off key here and those birds are actually rescue birds that are recovering; maybe all of the Australian birds have been rescued. But it felt like they were just inbred and weird. Yes it was mildly exciting with rainbow lorikeets (of all different cross breeds!) landing on my arms and shoulders to eat apple out of my hands, then squabble over meal worms…except for when one left a live meal worm on my neck!! Then they’d all take off at once and fly madly around the enclosure shrieking at full volume, not sure why. It was all just overwhelming and I just felt sad. I stopped taking photos and just watched them. Poor little things in cages. I didn’t say anything on the way out, just handed back the bowl and meal worm container and left. Then I stopped outside and shook all the spilled apple and bits of meal worms out of my shopping bag. Shaking the dust from my feet, so to speak.


Notice the olive backs and duller blue heads of two birds – a colour mutation apparently

I left there with a huge lump in my throat. Not like when you’re about to cry. It took me the drive home to realise that it was anxiety; I was seriously distressed! It was the kind of lump that you can’t swallow, and the more you try the more you feel like you can’t breathe and that right there is the beginnings of a panic attack!! Luckily I realised what is was in time, and starting taking long deep breaths and talking myself down but after a 15 minute drive home it still took me 3 tries to sign in to my computer with shaking hands, and my breathing is still a bit too shallow and fast…I’m working on it. I just feel dirty and bothered. I’m not much of a fan of birds in cages, although I’ve owned a budgy and ducks in my lifetime that were kept in cages. Sometimes it can be done really nicely, like the way that Zoos Victoria manage their aviaries with healthy happy breeding birds that stick to their natural patterns both at Melbourne Zoo and Healesville Sanctuary. This was just dirty and felt wrong.

Once I get past this, I’ll remember the good parts of the day that came before this experience. A drive around Hall Village, and some fun shopping at Gold Creek. But for now I need a distraction to clear my mind and wash it clean.

Maybe this would have happened anyway today, some anxiety, some panic; I don’t know. Today is a big day, other than the above: it’s moving house day! I’m sorry to leave my lovely brother and sister in law and Peanut, but it’ll be nice to spread our wings as grandma put it, and to leave my stuff all over the house! Hubby is already having nerves of his own over me spreading out, I’m sure!! Moving is a big deal because it means leaving the one comfort zone that I have in Canberra. Now everything is new: accommodation, still newish city, suburb, places. The quicker I make myself at home, and feel like its really home, the better. I had settled where we were, I knew my way around the suburb and into the city, I knew where the shops where that I needed, where to find the nature reserves. Now I’m starting over and that’s stressful to a degree. So maybe the anxiety was already there before the aviary and maybe it affected the way that I experienced it. Maybe I did overreact. Who knows? As always I’m trying to be positive and hold on to the thought that I can do this, but it takes a toll. Like packing took a toll; it really drained me! Partly because I didn’t want to pack up because it meant leaving, partly just because its tedious. The unknowns are always the killer for anyone with anxiety, depression, mental illness, and for other people to, I realise. They play on your mind until you’re frazzled and frayed. But positive thoughts right?

The other trigger for a panic attack today was thinking about someone I knew who passed away from suicide earlier in the year. I talked about it here. Somehow my head just got on that train of thought: how sick he was, how he’d always been impulsive, how awful things must have been for him to consider suicide, could anything have prevented it or was it inevitable, and so on. So I was probably in a funny frame of mind before the whole aviary thing. Not in a way that I was considering it for myself, just feeling bad for someone else to be that sick and understanding it.

Our apartment is on the second floor, a small flight of steps up and its small but I think we’ll be good here. One bedroom, small bathroom but big shower, cute small kitchen, full laundry in a cupboard, small verandah, and living/dining area, all designed for two. I don’t know if I could live in it forever but it’ll be grand for now. The one thing that I might struggle with is the underground car park…it’s fine I’m sure, but I just get a horror film/stalker type feeling going through the garage door…anyone know where I can buy pepper spray or a foghorn?

So to celebrate the occasion we had tea out altogether and a commemorative group photo with the self timer. The whole packing thing sucked, miscommunication causing some unpleasant moments with sulking and shouting! But we got there in the end, somehow; we seem to have expanded since we moved here. Well my stuff has, apparently hubby only has 2 bags, so why do I have so many bags??

And now to bed, I’m wrecked.