What's wrong with bugs in a pediatric infusion set?
On December 17, 2019, a foreign body incident occurred in the People's Hospital of Leshan City, Sichuan Province.
The father of the child found bugs in the infusion tube 5 minutes after the child's infusion. The nurse immediately stopped the infusion of the child, conducted a comprehensive examination of the child, and stayed in the hospital for observation for 17 hours.
The hospital will follow up the child later. The hospital apologized and was willing to take on the legal responsibility that should be assumed.
Image from the web
1. This incident is obviously a series of work mistakes
First of all, the manufacturer of disposable infusion tubes is Henan Shuguang Jianshi Medical Device Group. The infusion tube is a disposable medical consumable, which is disinfected and sterilized from the factory, and then sealed and stored, and the validity period is three years. Obviously, this is a non-conforming product. The manufacturer has made serious mistakes in the production and quality inspection links.
Second, the hospital nurse is to perform three checks and seven pairs before performing the infusion operation, but no bugs are found in this process, and there is also a great responsibility. Of course, it is not excluded that the bugs are hiding inside the switch, and the nurse did not see it when she helped to exhaust, and then came out with the flow of liquid and was found by the family.
Of course, no one wants to make a mistake. No health care worker wants that. The reality is that people make mistakes, do not cause losses, and are willing to take responsibility, which is a blessing in misfortune.
2. How to reduce mistakes at work?
We need to understand a concept: the confirmation of the difference
This story comes from "Controlling Habits"
It is said that the Japanese railway system is considered one of the best railway systems in the world. If you are inside Tokyo Train Station, you will notice that the staff has a very special habit.
During the train's operation, all the drivers will point to different objects and shout out instructions from time to time.
When the train approaches the signal, the driver will point to it and say, "The signal is green." "When the train goes in and out of the station, the driver points to the speedometer and shouts out the speed shown above. When the train leaves the station, the driver points to the timetable and shouts out the displayed time.
Every detail is confirmed, pointed out and shouted out. This process, known as finger error confirmation, is a safety system designed to reduce human error. It looks silly, but it works great. Finger error confirmations reduce errors by up to 85 percent and reduce accident rates by 30 percent.
The difference is so effective because it deliberately transforms some of our "brain-but-brain" subconscious behaviors into conscious behaviors that are "brain-online."
3. I have a similar "finger difference confirmation" in my life.
Every time before going out, I would say out loud: "Key monthly pass watch me." ”
Keys represent a variety of keys, including door keys, office keys, and car keys. The monthly pass represents a variety of "ticket-type things", including ID cards, driver's licenses, key cards, bus cards, etc. Watches represent electronic devices such as mobile phones and mobile phone power banks. And I, of course, took my old face with me in case I brushed my face.
It was very early in my life that I didn't know what was meant by "finger difference confirmation." The habit came from a joke.
In ancient times, there was a bad brain, that is, it was stupid. Once Yamen sent him to escort a monk who had committed a crime to another place. He was afraid that he would lose things and prisoners on the road, so he made up a slip of the tongue: paperwork, shackles, monks, and me. Easy to check before going on the road every day.
After spending a few days together, the monk found that the servant's brain was a little stupid. One day, they arrived in a town, and the monk invited the servants to drink in the tavern. The servant fell on the table drunk, and the monk put his shackles around the servant's neck and shaved a large bald head for the servant, after which he fled.
After the servant woke up drunk, confused began to check his own things. He chanted, "Clerical shackles monk me." He touched it in his arms, and the paperwork was still there. As soon as I raised my hand, I felt the shackles, and the shackles were there. He was wondering how the shackles had run over to him, when he touched his head and found that the monk was there. After that, he was even more confused, where did "I" go?
Although the story is funny, I have inadvertently learned to perform "finger error confirmation".
What other tips do you have at work to avoid mistakes?
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