[HSF] Safety in Medicine-Corrective courses

Wed Feb 6 18:07:05 EST 2008

Interestingly enough - contrary to my previous posting - a new JHACO
initiative is to insure the competency of all physicians - beyond CME and
Board Certification.  My understanding is that while there is no accepted
standard (yet) that each division, department, specialty, sub-specialty must
come up with a standard set of performance parameters to judge competency.
Failure to perform at acceptable standards will result in ??????.  This
should be fun......

-michael

On 2/6/08, Ajit Damle <damle at cableone.net> wrote:
>
> 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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