Major accidents, such as Three Mile Island or the Challenger accident, grab people's attention and make the front page of newspapers. Because they usually affect only one individual at a time, accidents in health care delivery are less visible and dramatic than those in other industries. Except for celebrated cases, such as Betsy Lehman (the Boston Globe reporter who died from an overdose during chemotherapy) or Willie King (who had the wrong leg amputated),2 they are rarely noticed. However, accidents are a form of information about a system.3 They represent places in which the system failed and the breakdown resulted in harm.
The ideas in this section rely heavily upon the work of Charles Perrow
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halfway through the surgery, the patient's blood pressure began to rise. The anesthesiologist tried to counteract this by starting one of the other infusion devices that had been set up earlier. He checked the drip chamber in the intravenous (IV) tubing and did not see any drips. He checked the IV tubing and found a closed clamp, which he opened. At this point, the second device signaled an occlusion, or blockage, in the tubing by sounding an alarm and flashing an error message. The anesthesiologist found a closed clamp in this tubing as well, opened it, pressed the re-start button and the device resumed pumping without further difficulty. He returned to the first device that he had started and found that there had been a free flow of fluid and medication to the patient, resulting in an overdose. The team responded appropriately and the patient recovered without further incident.
The case was reviewed two weeks later at the hospital's "morbidity and mortality" committee meeting, where the hospital staff reviews cases that encountered a problem to identify what happened and how to avoid a recurrence. The IV tubing had been removed from the device and discarded. The bioengineering service had checked the pump and found it to be functioning accurately. It was not possible to determine whether the tubing had been inserted incorrectly into the device, whether the infusion rate had been set incorrectly or changed while the device was in use, or whether the device had malfunctioned unexpectedly. The anesthesiologist was convinced that the tubing had been inserted incorrectly, so that when the clamp was open the fluid was able to flow freely rather than being controlled by the infusion device. The nurse felt the anesthesiologist had failed to check the infusion system adequately before turning on the devices. Neither knew whether it was possible for an infusion device to have a safety mechansim built into it that would prevent free flows from happening.
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"3 Why Do Errors Happen?."
To Err Is Human: Building a Safer Health System.
Washington, DC: The National Academies Press, 2000.
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