Monday, December 15, 2014

All That's White Isn’t Necessarily Propofol

With thanks to Saskatchewan's Health Quality Council Chairperson Susan Shaw for the reference, please check out this short article on a near miss in a large community hospital.

I have only one quibble with the author's choice of language.  She says:

As with any near miss or drug error, there were a series of unusual circumstances that led to this product being placed on an anesthesia table top. 

Actually, many such errors do not require a series of unusual circumstances.  It is the pattern of everyday work that often leads to preventable harm.

Meanwhile, with thanks to Jan M. Davies, Professor of Anesthesia & Adjunct Professor of Psychology, University of Calgary, I add this short video from George Carlin about "near misses."  Enjoy!


Neville Sarkari MD, FACP said...

Also, kudos to the CRNA for realizing that it even was a safety issue and writing the letter to the editor...!

Paul Levy said...