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	<title>Comments on: Holiday Blog Break</title>
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	<link>http://www.leanblog.org/2008/12/holiday-blog-break/</link>
	<description>Mark Graban&#039;s leanblog.org - Lean Healthcare, Lean Thinking, Lean Manufacturing, Toyota Production System</description>
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		<title>By: Mark Graban</title>
		<link>http://www.leanblog.org/2008/12/holiday-blog-break/#comment-4319</link>
		<dc:creator>Mark Graban</dc:creator>
		<pubDate>Fri, 26 Dec 2008 22:45:00 +0000</pubDate>
		<guid isPermaLink="false">http://leanblog.bigbigdesign.net/2008/12/holiday-blog-break/#comment-4319</guid>
		<description>Here is a google translation from French to English:&lt;br/&gt;&lt;br/&gt;&lt;a HREF=&quot;http://translate.google.com/translate?hl=en&amp;ie=UTF-8&amp;u=http%3A%2F%2Fwww.leparisien.fr%2Ffaits-divers%2Fmort-d-ilyes-a-l-hopital-le-flacon-n-etait-pas-a-sa-place-25-12-2008-353629.php&amp;sl=fr&amp;tl=en&amp;history_state0=&quot; REL=&quot;nofollow&quot;&gt;LINK&lt;/a&gt;&lt;br/&gt;&lt;br/&gt;Part of the translation:&lt;br/&gt;&lt;br/&gt;&quot;The nurse has admitted to mistakenly given the child an infusion of magnesium chloride instead of glucose intended to rehydrate. This misunderstanding might have caused a cardiac arrest of the child who had been hospitalized for angina.&lt;br/&gt;&lt;br/&gt; The nurse, aged 35, was under investigation Friday for &quot;involuntary homicide&quot; and placed under judicial control. It was referred to in the afternoon at the public health division of the Paris court where the judge Marie-Odile Bertella-Geffroy has held against him &quot;a simple negligence, recklessness or carelessness.&quot; &quot;&lt;br/&gt;&lt;br/&gt;As I&#039;ve written about before, I&#039;m not a big fan of filing criminal charges against an individual for what&#039;s most likely a process problem. What responsibility did hospital management and leadership have to make sure processes were error proofed so the wrong med can&#039;t be given to the wrong patient?&lt;br/&gt;&lt;br/&gt;We need to focus on prevention and learning, not punishment.</description>
		<content:encoded><![CDATA[<p>Here is a google translation from French to English:</p>
<p><a HREF="http://translate.google.com/translate?hl=en&#038;ie=UTF-8&#038;u=http%3A%2F%2Fwww.leparisien.fr%2Ffaits-divers%2Fmort-d-ilyes-a-l-hopital-le-flacon-n-etait-pas-a-sa-place-25-12-2008-353629.php&#038;sl=fr&#038;tl=en&#038;history_state0=" REL="nofollow">LINK</a></p>
<p>Part of the translation:</p>
<p>&#8220;The nurse has admitted to mistakenly given the child an infusion of magnesium chloride instead of glucose intended to rehydrate. This misunderstanding might have caused a cardiac arrest of the child who had been hospitalized for angina.</p>
<p> The nurse, aged 35, was under investigation Friday for &#8220;involuntary homicide&#8221; and placed under judicial control. It was referred to in the afternoon at the public health division of the Paris court where the judge Marie-Odile Bertella-Geffroy has held against him &#8220;a simple negligence, recklessness or carelessness.&#8221; &#8220;</p>
<p>As I&#8217;ve written about before, I&#8217;m not a big fan of filing criminal charges against an individual for what&#8217;s most likely a process problem. What responsibility did hospital management and leadership have to make sure processes were error proofed so the wrong med can&#8217;t be given to the wrong patient?</p>
<p>We need to focus on prevention and learning, not punishment.</p>
<p>Like or Dislike: <img style="padding: 0px; border: none; cursor: pointer;" onmouseover="this.width=this.width*1.3" onmouseout="this.width=this.width/1.2" id="up-4319" src="http://www.leanblog.org/wp-content/plugins/comment-rating/images/1_14_up.png" alt="Thumb up" onclick="javascript:ckratingKarma('4319', 'add', 'www.leanblog.org/wp-content/plugins/comment-rating/', '1_14_');" title="" /> <span id="karma-4319-up" style="font-size:12px; color:#009933;">0</span>&nbsp;<img style="padding: 0px; border: none; cursor: pointer;" onmouseover="this.width=this.width*1.3" onmouseout="this.width=this.width/1.2" id="down-4319" src="http://www.leanblog.org/wp-content/plugins/comment-rating/images/1_14_down.png" alt="Thumb down" onclick="javascript:ckratingKarma('4319', 'subtract', 'www.leanblog.org/wp-content/plugins/comment-rating/', '1_14_')" title="" /> <span id="karma-4319-down" style="font-size:12px; color:#990033;">0</span></p>]]></content:encoded>
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		<title>By: Anonymous</title>
		<link>http://www.leanblog.org/2008/12/holiday-blog-break/#comment-4318</link>
		<dc:creator>Anonymous</dc:creator>
		<pubDate>Fri, 26 Dec 2008 22:07:00 +0000</pubDate>
		<guid isPermaLink="false">http://leanblog.bigbigdesign.net/2008/12/holiday-blog-break/#comment-4318</guid>
		<description>Hello&lt;br/&gt;&lt;br/&gt;Well, while you are on holidays, Hospital not-Lean management is making big headlines here in France.&lt;br/&gt;url&lt;br/&gt;http://www.leparisien.fr/faits-divers/mort-d-ilyes-a-l-hopital-le-flacon-n-etait-pas-a-sa-place-25-12-2008-353629.php&lt;br/&gt;&lt;br/&gt;Short passage translation:&lt;br/&gt;&quot;According to a source, both bottles were extremely similarly looking, with same cap and same blue label even if label text, B46 for one and magnesium chloride for the other, were different.&quot;</description>
		<content:encoded><![CDATA[<p>Hello</p>
<p>Well, while you are on holidays, Hospital not-Lean management is making big headlines here in France.<br />url<br /><a href="http://www.leparisien.fr/faits-divers/mort-d-ilyes-a-l-hopital-le-flacon-n-etait-pas-a-sa-place-25-12-2008-353629.php" rel="nofollow">http://www.leparisien.fr/faits-divers/mort-d-ilyes-a-l-hopital-le-flacon-n-etait-pas-a-sa-place-25-12-2008-353629.php</a></p>
<p>Short passage translation:<br />&#8220;According to a source, both bottles were extremely similarly looking, with same cap and same blue label even if label text, B46 for one and magnesium chloride for the other, were different.&#8221;</p>
<p>Like or Dislike: <img style="padding: 0px; border: none; cursor: pointer;" onmouseover="this.width=this.width*1.3" onmouseout="this.width=this.width/1.2" id="up-4318" src="http://www.leanblog.org/wp-content/plugins/comment-rating/images/1_14_up.png" alt="Thumb up" onclick="javascript:ckratingKarma('4318', 'add', 'www.leanblog.org/wp-content/plugins/comment-rating/', '1_14_');" title="" /> <span id="karma-4318-up" style="font-size:12px; color:#009933;">0</span>&nbsp;<img style="padding: 0px; border: none; cursor: pointer;" onmouseover="this.width=this.width*1.3" onmouseout="this.width=this.width/1.2" id="down-4318" src="http://www.leanblog.org/wp-content/plugins/comment-rating/images/1_14_down.png" alt="Thumb down" onclick="javascript:ckratingKarma('4318', 'subtract', 'www.leanblog.org/wp-content/plugins/comment-rating/', '1_14_')" title="" /> <span id="karma-4318-down" style="font-size:12px; color:#990033;">0</span></p>]]></content:encoded>
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