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.

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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

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