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!!!

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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!!

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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 Four

[Friday 14th October 2016]

Today was a great day! Not every moment, but wouldn’t that be asking a bit much in ordinary situations? But the not-so-great moments got turned around to become something good so all in all I’m stoked. I really enjoyed myself today! It started with a plan of what to do for the day. The last couple of days have been less than productive, which I don’t enjoy, and after all its day 34; time is cracking along! More than a month already, can you believe it? On days where I wake up and don’t have a plan for the day, they tend to be the days that I roll over and go back to sleep, because why not, and drift aimlessly through to early afternoon before making up my mind about what to do then having to rush about to do it, or missing the chance. So I decided Thursday night that before I went to bed I was making a plan, and when morning came I was sticking to it. The plan that Chester and I came up with was to wake up, get dressed in my cycling gear and ride my bike down to one of the streets in our new suburb that has a lot of eateries. I would go to Eighty Twenty café that hubby recommended and have breakfast, then check out the bike path that runs along Sullivan’s Creek, somewhere that I’d seen and wanted to check out, and that hubby has ridden part of, I think. And I did! Add in the bonus of remembering to call at the bike shop and get a bracket so I can attach my mobile phone to my handlebars for GPS on the go. Minus not actually navigating my way successfully to Sullivan’s Creek after my phone went flat and rendered my new bracket moot!! I haven’t really got my directions at this new place, and all the through roads around here have bends in them! What a crazy situation! So you just think you’ve gotten your bearings and the road take a 45 degree bend! Now where are you? But in the process I was in sensory heaven soaking up the lush green budding and leafy trees forming avenues over the roads, and the beautiful flowering gardens in all colours with some trees still blossoming, and well-kept front areas of houses in our neighbourhood, and probably the bordering suburbs as well; not really sure where I went! Eventually I hit Anzac Avenue which was somewhere well in the wrong direction from where I was meant to be, then my phone died, so I had a lovely meandering time trying to figure out how to get home! It was actually just so nice to dawdle around checking out the gardens and lawns, and taking detours wherever I wanted. Luckily I’d picked up some names of street nearby to ours already…remembering this is day 3 living in this new place!

I got home and felt like I could go for more so I did another street and luckily came around the block back again. All up about 9km but just a good amount to get going again. I haven’t ridden for a couple of weeks with rain, then wind, then pervasive disinterest! So it was good to feel like I can still do it, and still get that nice little spike of feel good from rolling around the suburbs on my bike. Plus the weather just turned any outdoor activity into sheer bliss! 20 degrees, chill breeze, blue skies making for great biking. That ride set me up for the rest of the day. Everything else good that happened after felt like it happened because of the ride.

I mentioned breakfast was at Eighty Twenty in Braddon on Lonsdale Street. Quite lovely, but I found the menu a bit challenging; not your standard egg and bacon! More your quinoa, nuts, almond milk, home baked granola type place, but in the end I did have their smashed avocado on toast with 2 eggs and 3 bits of asparagus on top and peas and feta around the plate. It was delicious actually, I’d have it again for sure. Just to show you can have eat-out breakfast without bacon! Sitting in the sun with my bike next to me did fill me with some feelings of accomplishment. Here I’d planned this thing that I’d been putting off really for the last week or two, and I was doing it! I can follow through. I’m not a wash out, a failure, useless. I can do it, and the proof is that I did do it! So nothing to stop me next time, hey? Except carrying my bike down the stairs from our level one apartment; that’s not an easy feat! I guess practice makes perfect.

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SO what else to do on a sunshiny day but tackle something I’ve been wanting to do: check out the Mount Ainslie lookout. I went once before you might remember but it was in a cloud and you couldn’t see a single thing! Today you could see forever or to the beautiful blue hills that border Canberra. Blue skies, sunshine, and the view is spectacular! Always worth the short drive up. I went planning on getting view photos only, but thought I’d walk along a short track back from the lookout itself, heard a bird and it was an hour and a half later when I looked up! Only two rows of trees, one on either side of me, one tree deep, but I got some spectacular birds! Great photos and extended views of a bird I’ve only seen once and got one muffled shot of that first time, a lifer in a Little Eagle soaring above (that was exciting, never forget to look up!), and other interesting birds being very conducive to photos! And I didn’t even have to try, they were all just there, going about their business. The best way to watch birds!

Went home for a nap, but was too excited to look at the photos from the morning. That was a task well worth doing because I found there were 2 different species of bird that I’d photographed but hadn’t realized what they were! Two more for the morning’s list! I knew they were something different but they were too far away; luckily my camera brings them closer J

It was all too exciting, so after a couple of hours I headed back to find the actual trail. Not the Kokoda trail near the lookout; that’s for mountain goats! So I headed down the hill looking for a trail. Not the old tip trail, it’s too rough and large gravel and steep; I’d do an ankle! Not the next one down; its appears to go into the shooting range from the back! So it turns out that the trail I did way back last year when we were here for our hosts wedding was the best one, and the one I should be doing. They need to make a brochure like they have for Black Mountain; it would save a lot of precious birding time, wandering all around everywhere. The first half of the walk was in the wrong direction really, but because there weren’t many/any birds other than the pesky Noisy Miners (!) I kept up a bit of pace and did a pretty nice 2km walk before (re) finding the best spot. So I had my eyes open to other things: rabbits, kangaroos, a cute echidna! And everlasting daisies, tons of them! They are all just about to open the buds; I’ve made a date to go back next week and check it out.

Two successes of my later birding walk were walking alone in the bush (although I have been building a tolerance to this with lots of walks lately, this one was a bit more removed from carparks and passersby) and walking alone in the bush at dusk approaching dark. My recent anxiety flare up has brought these closer to the front of my mind again which is a pest! I’d squashed them down nicely for quite a while. I’ve always been terrified of the monsters in the dark. We had an outside toilet as kids and whatever age I was I’d still wake one of my parents to go with me. But it didn’t stop me having to bite the bullet of the adrenaline rush that was running from the back door to the toilet door in the direct and utterly exposed lie of fire of those who waited at 2am on the other side of the green mesh wall to gun me down for some unapparent reason!! I was always terrified of gun men, and kidnappers, and rapists. I still am to a degree, but I’m more rational in questioning the reason: a) why anyone would want to shoot me, b) why they would wait in the cold all night right there near the toilet in case I needed to go to the toilet, c) how they would know the layout of our house and toilet, d) why they would shoot a child with a shot gun (the only gun I knew, and so assumed they had) and so on. If you start thinking like this it does all start to crumble, but you have to make that conscious switch to think like that, which is indeed the challenge. Anyhow, you’ll be pleased to hear that no thugs or bandits were crouched behind tree stumps in an enormous area populated by a whole 2 walkers waiting to loot us and so on. I returned to my car, by this time practically in the dark, unharmed, and with only a little adrenaline coursing through my veins. And so concluded my happy day! Exercise, the beautiful outdoors, challenging myself to eat outside my comfort zone, finding my way around new suburbs unaided, beauty and birds to be photographed; how lucky am I? A low key dinner and sitting on the couch to end a wonderful day.