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