Lack of CT Scan Error Proofing Leads to Death

WOAI: San Antonio News – Woman Dies after Medical Mistake at CTRC

An 81 year-old woman died tragically after she was injected with 100cc of air instead of contrast die before a CT scan.

The documents also state, “Found to have been injected with approximately 100 CC of air and suffered massive air pulmonary embolism.”

That’s right. Somehow, CTRC accidentally injected Ila with air, causing cardiac arrest. Cynthia says she was never told by anyone at either place about what really happened.

The article here talks about “what” happened. To the credit of the reporters, blame isn’t assign to an individual. But here’s a challenge for the healthcare world: how do you error proof this so that it never happens again, anywhere?

It might be a great opportunity for standard work and checklists… but is that true error proofing? It constantly amazes me that aviation requires checklists for just about everything, even the pilots. This helps prevent errors. But we don’t have the same standard applied within healthcare. We need to do better than this.

We can’t just ask “who messed up?” in this case. We can’t assign blame. We have to ask “why did this problem occur?” Use the lean “5 Whys” problem solving method. Keep asking why until we get to a true root cause that can be permanently eliminated.

I’m just speculating here….

“Why did air get injected by mistake?” If an answer is “the technician was tired and overburdened”, we have to ask “why was that?” It could be tied back to staffing levels, the length of shifts, a lack of a standard checklist, a lack of quality checks in the process. Who knows. But it’s more than likely a systemic problem rather than being the gross incompetence of one person to blame.

The article also talks about how the hospital tried to cover up the real cause of death with the family. Sad stuff all around.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology, focused on improving quality and patient safety, improving access, reducing costs, and fully engaging healthcare professionals. He is also the Chief Improvement Officer for KaiNexus.