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Thanks for the response. The extensive work on aviation safety has shown that there is rarely a single cause of any accident or a single solution to prevent it happening again. I totally agree about the need for standardisation. The disagreement is about which are the preferred units. I have two reasons for preferring molar units. 1 As I read the relevant standards there is no ambiguity: molar units are preferred for this purpose. 2 "Molar thinking" is useful in understanding calculated osmolality, calculated anion gap, acid-base chemistry etc. Jonathan On 8 Feb 2007, at 12:50, Reynolds Tim wrote: > Does it matter! > > If we were in the aviation industry and crashes were shown to be > because > some repair men used BNF bolts and others used UNF, there would > immediately be standardisation. > > So when instead of 300 people dying at once only one does it, why > do we > endlessly debate how many angels can dance on the head of a pin > (depends > on the molarity or mass of the angel - heavy ones might hurt their > feet)... > > TIM > > > -----Original Message----- > From: Clinical biochemistry discussion list > [mailto:[log in to unmask]] On Behalf Of Jonathan Kay > Sent: 08 February 2007 12:48 > To: [log in to unmask] > Subject: Misinterpretation of units has proved fatal > > > Thanks. > > 1 Do you know the content of the report from the laboratory? (Eg did > it include units?, had it turned into just a verbal transmission of a > number?) > > 2 Do you know which treatment guidance the clinician was using? (Eg > the BNF (which it sounds like)) > > 3 Do you know how the long the doctor had been working in that > department? > > Jonathan > > > On 8 Feb 2007, at 12:37, Julian Barth wrote: > >> Dear Colleagues >> >> Further to my previous mailings about the need to standardise the use >> of drug units in the UK using the Consensus recommendations, I would >> like to bring to your attention a recent fatality due to a >> misunderstanding directly related to the confiusion of units. >> >> A case of paracetamol overdose occurred in which the interval between >> the possible paracetamol overdose and the blood sampling was not >> known. >> The concentration obtained was 2.29 mmol/L. the doctor who >> interpreted >> the result used the 'mg/L' scale, which suggested that the value was >> very low and not requiring action. The mmol/L scale was not used >> because >> the value obtained was off this scale (which only goes up to 1.3 >> mmol/L). The patient eventually died. >> >> This episode is further evidence that the status quo, with different >> labs reporting in different units, is associated with avoidable >> clinical >> risk. It adds further support that we must act now or else a solution >> will be forced upon us. I sincerely hope that any waverers will be >> convinced of the need by this case. >> >> With best wishes >> Julian >> >> >> Julian H Barth MD FRCP FRCPath >> Consultant in Chemical Pathology & Metabolic Medicine Department of >> Clinical Biochemistry & Immunology Leeds General Infirmary >> Leeds LS1 3EX >> >> tel 0113 392 3416 >> fax 0113 392 5174 >> >> Editor-in-Chief, Annals of Clinical Biochemistry, >> journal http://www.ingentaconnect.com/content/rsm/acb >> submissions http://mc.manuscriptcentral.com/acb >> >> - ------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/