Thursday, March 26, 2009

Prevention

Wonderful task...

Well, not really researchable, so my response was to sit in the library in silence for 45 mins and brainstorm. Here goes:

For the individual, Josh in this case, there is little chance of him actually repeating the error. Presumably, after the event he would both research the relevent anatomy and procedural details, and would also probably ask for specific instruction and demonstration from a senior doctor.

In terms of the Hospital, or the overall system, they could help prevent such errors in the future by:
-Reinforcing emergency protocol and hierarchy affairs (eg what can be expected of new doctors)
-Hospital training on emergency management and procedures
-systems design of the ED - locations and proximity of staff, triage grading system
-Procedural instructions made available with the instrument (chest tube)
-Upgrading/renewing reporting and reviewing systems
-Clinical schooling upon induction to the hospital, to assure an appropriate level of knowledge.

sources: none really, though there's an interesting text called "To Err is Human"

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