Recently, nine patients died in Alabama when they received intravenous nutrition that was contaminated with deadly bacteria. This type of nutrition is called total parenteral nutrition, or TPN, and is used to nourish patients by vein when their digestive systems are not functioning properly. It is a milestone achievement in medicine and saves and maintains lives every day.
What went wrong? How did an instrument of healing become death by lethal injection? What is the lesson that can emerge from this unimaginable horror?
This tragedy represents that most feared ‘never event’ that can ever occur – death by friendly fire. No survivors. Contrast this with many other medical ‘never events’ as defined by the Centers for Medicare and Medicaid Services, such as post-operative infections, development of bed sores in the hospital or wrong-site surgery. Under the ‘never events’ program, hospitals will be financially penalized if a listed event occurs. Many physicians and hospitals are concerned that there will be a ‘never events’ mission creep with new outcomes added to the list that don’t belong there. Medical complications, which are unavoidable, may soon be defined as ‘never events’.
Do we need a new category of ‘never ever ever events’ to include those that lead to fatal outcomes? Read more »
*This blog post was originally published at MD Whistleblower*
It’s going to take a while to draw all those labs. And the patient will probably need a transfusion at the end of it.
(Reportedly the printer engaged itself in a loop and printed out blood culture label sets 25 times, so don’t panic).
*This blog post was originally published at GruntDoc*
I personally find the word-completion tool kind of annoying on the iPhone – especially as a doc. The software is geared towards choosing the most common word after a few letters, and you can bet that physicians are not typing out common words. Like “emycin” is not “empty” – I’m just sayin’.
A couple of awkward ones recently – my friend was texting me about a tragic and unexpected event and I responded with “Geeze!” which (as I pressed send) turned into “Geese!” That one was hard to explain, and quite insensitive at the time. Err…
Another friend of mine was dealing with a sick kitty at home. She had taken the cat to the vet because she’d stopped eating/going to the litter box. The kitty was diagnosed with an infection and was on the road to recovery, when a couple days later she had her first bowel movement. So my friend decided to text her husband the good news via her iPhone. She typed “the cat went poo,” but alas, the iPhone had the last word. Her husband received this alarming, if not perplexing text message:
“the cat went pop”
Have you had similar iPhone drama? Do share…