Information and Communications

There are circumstances that make management of trauma patients unlike any other medical emergency. When treating trauma patients, the physicians and nurses often have very little information and no medical history for the patients. In the story, Jennifer Kung received only a few pieces of information about John Doe when she spoke to the paramedic in the field. Ben was unaware that no intravenous access had been obtained because John Doe was a drug abuser. Stuart had no idea that John Doe was...

References

Error It's what, not who. TraumaCare, 8(2), 82-84. Bogner, M. S. (2000). A systems approach to medical error. In C. Vincent & B. De Mol (Eds.), Safety in medicine (pp. 83-101). Amsterdam Pergamon. Bogner, M. S. (2002, Spring). Stretching the search for the why of error The systems approach. Journal of Clinical Engineering, 27(2), 110-115. Brown, S. L., Bogner, M. S., Parmentier, C. M., & Taylor, J. B. (1997). Human error and patient-controlled analgesia...

The World Of The Anesthesia Care Provider

To understand Jessica's world and the role equipment alarms play in it, we first must understand what an ACP does in and around the OR. The ACP has responsibility for patients from the time they are taken from the preoperative area and brought into surgery until after completion of surgery when they are handed over to qualified recovery room personnel. The ACP uses gases and intravenous drugs to induce a state of anesthesia in the patient and assumes responsibility for maintaining all the vital...

Transfusion Issues

The preceding story is fiction, but it was inspired by actual events. The incident is typical in that there were multiple errors and multiple missed opportunities to have prevented the tragic outcome. Although many patients facing transfusion are most concerned about the risk of transmission of human immunodeficiency virus (HIV), few are concerned about receiving the incorrect blood through error. The risk of HIV transmission has been estimated at about 1 700,000, with the aggregate risk for...

Alphonse Chapanis Professor Emeritus Johns Hopkins University

The second half of the 20th century has witnessed advances in medical practice and technology that can only be described as spectacular. The discovery of penicillin in 1928 and its first use to treat wounded soldiers in World War II forecast a dramatic increase in the number of drugs available to the modern practitioner. Not only have new drugs appeared in profusion, but also new methods of manufacturing them genetic engineering, for example have been devised. As a result, the U.S....

The Elephant Of Error

In the fable, a man who has never seen an elephant is blindfolded and asked to describe the elephant based on information he obtains from feeling the elephant with his hand. The man's hand is placed on the elephant's leg from that information, he declares that the elephant is like a tree. The blindfolded man's hand then is placed on the elephant's trunk from that information, he states he was wrong before, that the elephant resembles a serpent. When the blindfold is removed and the man sees the...

Adverse Outcomes Reflect Systems Issues

Jessica's experiences highlight the fact that adverse outcomes are the result of multiple system factors that impact the care provider, rather than the result of an act perpetrated solely by an individual. It is always possible to point to a superficial reason for an accident but it is impossible to find a single underlying cause (Senders & Moray, 1991). In other words, Mr. Blevsky's hypoxia and his subsequent brain damage can be explained in terms of the events that led to those conditions...

Icu As The Temple Of Technology

The hospital ICU is dedicated to the care of the seriously ill patient. ICUs typically are equipped with the most advanced medical technology and are intended to provide patients with the best medical care available. Nevertheless, care in the ICU has been found to expose patients to substantial risk resulting from the limited ability of the persons working in this environment to cope with both the technology and the enormous amount of data presented to them. To respond to a change in the...

Christine L Mac Kenzie Alan J Lomax Jennifer A Ibbotson

LAPAROSCOPIC SURGEON, DAVE GARDNER, M.D. The surgeon, Dave Gardner, was having a hard time. Although he was an experienced and competent surgeon, the minimally invasive (often referred to as keyhole surgery because of the small size of the incisions) laparoscopic cholecystectomy, or gall bladder removal, for Mrs. Sanders was proving to be extremely difficult. The operation started out as usual Dave made four small incisions, each about half an inch long, in Mrs. Sanders' abdomen. He inserted...

Yoel Donchin

Hadassah Hebrew University Medical Center INTENSIVE CARE UNIT ATTENDING PHYSICIAN, WILLIAM JONES, M.D. Dr. William Jones, the attending physician in the intensive care unit (ICU), works 5 days a week, is well paid, does not have to pay loans, and is in good health. His medical training was in anesthesia he has had experience working in the ICU. He enters the ICU at 7 a.m. relaxed and confident to start another day. The minute he enters the ICU, he is exposed to its unique and noisy environment,...

Blood Bank Errors

Blood bank procedures are highly regimented however, the procedures are effective only if they are followed. There are many steps in the procedures with the potential for an inappropriate action. One such step is testing. Blood bank testing errors account for about 15 of transfusion errors (Linden et al., 2000 Sazama, 1990). Testing presents many opportunities for error. In typing the sample, a blood bank staffer could take the wrong patient's sample from the test tube rack and use it for...

Identification Errors

Administration of blood to the incorrect recipient constitutes the largest single human error in the transfusion system, accounting for about 40 of cases Linden et al., 2000 Sazama, 1990 Taswell, Galbreath, amp Harmsen, 1994 Tissier, Le Pennec, Hergon, amp Rouger, 1996 . Figure 2.1 illustrates a nurse administering a unit of blood. In many cases, the person administering the blood usually a nurse assumes that the blood received is for a patient for whom blood is expected and administers it...