Swiss Cheese

They say*

That clinical error

is like

Swiss Cheese;

You line-up the holes,

twist and turn

through happenstance

and

bad luck

and

eventually

If you are lucky

You survive.

And, if you’re not,

the allergy is missed and the check and the dispense and the doctor and the nurse and the pharmacist are all perfectly aligned

like the stars

on

Skara Brae.

*James Reason