[HSF] Safety in Medicine-Corrective courses

Wed Feb 6 15:24:28 EST 2008

I have no idea. For all I know, that is just window dressing.

Ajit Damle

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Dr. Roberto
Battellini
Sent: Wednesday, February 06, 2008 2:39 PM
To: OpenHeart-L at lists.hsforum.com
Subject: AW: [HSF] Safety in Medicine-Corrective courses

Can you tell us more about corrective courses? For doing that one must admit
error.
Roberto

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Ajit Damle
Gesendet: Mittwoch, 6. Februar 2008 06:25
An: OpenHeart-L at lists.hsforum.com
Betreff: [HSF] Safety in Medicine

Dr. Bidstrup, you are absolutely right.

We in Medicine are so far behind, almost to the point of negligence, and
avoid simple industrial quality principles. I do hope that the we have our
next major change, is in basic patient safety, on par with the discovery of
antibiotics, joint replacements, coronary stents and so on. 

Last year, one of my anesthesiologist colleagues injected scoline, instead
of saline, to flush a pre-op CVP line prior to a valve repair. Fortunately
this happened in the holding room, and the nurse immediately diagnosed the
respiratory arrest, and all was well in end. If this had happened on the
floor, it probably would have passed off as just another  cardiac arrest.
The anesthesiologist, an experienced, dedicated physician was severely
reprimanded, had to undergo corrective courses and so on. But will that stop
from for this happening again to some other physician? I doubt it. If only
we had a "cockpit resource management".

I am sure you have several examples that you have seen. A while ago, there
was a survey of cardiac surgeons regarding CPB accidents, particularly air
embolism. Surgeons anonymously described their horror experiences, and that
has indeed, over the years, translated into better resident training for CPB
conduct.

The Institute of Medicine estimates that up to a 100,000 patients are
seriously harmed in the US because of preventable iatrogenic errors.
Curiously, it is difficult to find hospitals or doctors who see this in
their personal setting.

Ajit Damle

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Ben Bidstrup
Sent: Tuesday, February 05, 2008 9:08 AM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Intimal Tears

This is an important issue esp with regard to visual appreciation of 
data. (see Tufte ).

Do we have distinctively labelled ampoules for each drug and rely on 
the colour/shape and position to identify the drug or do we have them 
all the same and force a look at the writing on the label. After all 
this is the process for blood transfusion.

I saw protamine which was in a similar coloured ampoule to heparin 
given at the beginning of a case. Blood for flushing the vein clotted 
in the bowl as the arterial cannula was going in. The OR Nurse (my 
wife) stopped us from going further - until we were sure.

Great example also of cockpit resource management (see articles by 
Healy and others). BTW that happened nearly 25 years ago! Before CRM 
was really fully developed.

>I once had a trainee perfusionist  give noradrenaline  instead of
Adenosine.
>The company used to making the ampoule's had made the packaging similar and
>also nearly similar sounding names.He had prepared the cardioplegia and was
>running the pump undr supervision of a qualified perfusionist. He was a
>pretty sharp boy and in hind sight the making of the cardioplegia and
>laoding of syringes was not physically monitored.
>Every time cardioplegia was given the BP shot up to MAP's of 150 and I was
>wondering what was happening and I asked then to check the cardioplegia.
The
>boy himself diagnosed the problem and the cardioplegia was immediately
>changed. Surprisingly the patient did extremely well (So much so that I
>joked that maybe it couldbe added as a cardioplegia additive. I later
talked
>to the company and asked them to make distinctive packaging for the same
>apart from making the perfusionists double anccross check every drug as a
>part of the protocol. It was a lesson both the boy and myself did not
>forget. He has become a very good perfusionist now.
>Prasanna
>On Feb 5, 2008 6:32 AM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:
>
>>  Hal
>>
>>  Yes it was a resident who was not not appropriately supervised. We had
all
>>  sorts given through the line - vasopressin, norepinephrine, propofol -
for
>>  several hours before recognized. Complication was ultimately fatal.
>>
>>  Ani
>>
>>
>>
>>
>
>
>--
>Prasanna Simha M
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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