We can all think of doctors who are less than ideal. They might be rude or arrogant or uncommunicative. Recently, I was unfortunate enough to witness a doctor who is barely safe.

This doctor doesn't understand many disease processes they treat on a daily basis. This doctor doesn't understand the key points of presentations or what they mean or why, if untreated, the patient is in the deep end. This doctor cannot 'hand over' care of a patient to another doctor clearly, accurately or concisely.

The doctor concerned, lets call them Dr F, applies an algorithm to each diagnostic scenario. This approach isn't entirely flawed, in fact, it's often a good way to go, especially if you've got no idea what's happening and you have minimal experience. Importantly, every part of the algorithm needs to be remembered for it to be valuable. And you'd think that with several years of clinical practice under the belt, Dr F would begin to understand what is happening, and why it happens. I'm pretty sure they don't.

Several years ago, I wrote about the Clinical Creep. A jerk of a doctor, to be sure, but a very different beast to Dr F. Essentially, I think that my problem with Dr F is that despite their efforts to be active with their assessments, plans and management, they just seem to miss the point. It's a bit scary.

I appreciate that I'm at the bottom of the clinical tree, and Dr F is several steps above me on the ladder, but I'm just befuddled at how they made it this far. Thankfully, Dr F's superiors are aware of the problem. I wonder what will happen next.

Two teenagers are on the ward, same age. They dress similarly, have similar interests and are the same sex. They don't know each other from a bar of soap.

Both showed up with serious symptoms with potentially life-threatening differentials.

The first knew their symptoms were serious, the other suspected. The first was scared; properly scared. The second was quiet, contemplative. Both kids smiled, just once or twice, in spite of their condition.

The first was investigated and diagnosed with a relatively minor ailment. The second was also investigated and diagnosed with a similar ailment. Both need inpatient treatment.

The next day, the first is surrounded by peers vying for attention; oohing and aahing over the surrounding medical paraphernalia, the patient is cocky, confident, riding the attention. The second sits quietly listening to an iPod, reading.

As they both get better the first's mother says, "Can they go home yet!?". The second's mother asks, "Is my child safe to come home?"

Both go home, safely. The first with fireworks and ceremony. The second calmly picks up the overnight bag, smiles awkwardly at mum as they leave ward.

We all approach mortality with a different style. Our insecurities, however universal, manifest individually.

Mistakes rarely manifest as split second incorrect decisions. Sure, in Pharmacy, dishing out the wrong medication often involves a short, momentary, lapse of concentration where the deed occurs. But many other errors, as such, occur through misreading a situation over a period of time.

We often hear of a patient whose diagnosis was 'missed'. Often these diagnoses are not glaringly obvious. The picture changes over time; it's when there is a level of clinical dissonance the doc needs to rethink their diagnosis. There are many possible outcomes for any given constellation of presenting complaints.

These thoughts wafted into my conscious early this morning, about halfway through a cycling race. In previous cycling races I've been in, when the breakaway jumps off the front of the race, either you see it coming or can react fast enough to go with it. From this piece of information and the fact that my mind was wandering to medical errors, pharmacy and planning a blog post, all whilst racing, you would assume, right then and there, I missed the break.

But today's race was in the hills. Plenty of time to think whilst two young fellows managed to make the weaker riders do all the work, and one by one, we all ran out of puff. Then could they ride away to the victory, we other riders turning the pedals and going nowhere as they launch off to victory.

So, about the time I'm sitting on the front, mind wandering into fairyland and using my energy to maintain a decent pace, something clicks. This is where the mistake happens. For me, it was a cascade of errors; taking a turn at the wrong point, staying on the front too long, burning up energy earlier than necessary, not really concentrating of when to save or burn energy.

And, in fact, the vast majority of medical and pharmacy errors appear to occur the same way. As I discovered during my PharmSchool research project, the literature describes it as a Swiss Cheese model. Only when slices of Swiss Cheese line up, can a certain trajectory of error pass through.

In pharmacy, this is characterised by multiple procedures, checks and double checks for each 'script. In medicine immediate analysis occurs by peer-reviewed diagnostic and management plans; and retrospectively by Morbidity and Mortality(M&M) conferences.

In these meetings, clinicians analyze situations that are considered to be less than ideal, either for the outcome of the process. My previous impression was that M&M was a bit of a witch-hunt; a finger-pointing exercise. They're not.

In the ideal M&M meeting, the scenario is reproduced objectively, and the other clinicians challenged to think;

"What would I do here? What am I concerned about? What information do I need to gather?"

At a particular time point.

Decision making becomes much easier if you already have all of the information, and a 20:20 retrospectoscope. In real life, decisions are made much earlier, borne of necessity with the information available at the time. Often cases in the M&M meetings have a "swing point", where suddenly everything comes together, just like an episode of House MD. In M&M cases, that point is "too late". In near misses, that point is "just in time". In most cases, the ones that are well handled, that point happens well before the critical time. Long before the break has gone and the teenagers have ridden everyone to the ground.

Mistakes happen. The best we can do is to learn from them, analyze them, and try our level best not to repeat ours or others. But they happen. That's medicine and that's life.

Her hands adjust her rings nervously. Anxiously, she twists them 'tween forefinger, thumb each adorned with fake pink tip and sparkling butterfly. The nicotine stains are deep.

She looks through the window at the small boy as he watches television.

She's barely fifty, crows feet scrabbling at fading eyeliner and foundation, small lips dry, voice leathery. She says;

"He's not my son, I'm trying my hardest."

He's not her son. Her daughter has gone somewhere else. Her daughter now comes and goes in both mind and body. Most days, her daughter forgets she has a son. This boy.

The woman is trying hard. She is a flight attendant, she's only new. Her shifts are fifteen hours, six days a week. She's a busy lady, and besides, money is a problem for just her, let alone a kid. She sighs and looks away. Her partner doesn't like the boy either. She's barely home.

He's better now, fixed up in hospital. He's not a well child; he needs care and love.

He watches television. Unwanted.