This is a 31 minute YouTube video from the Risky Business conference highlighting the story of Julie, a nurse, and what happened after she connected a patient to the wrong drug infusion pump. The patient died and Julie lost her job.
“There will never be a point when you have achieved enough skill, experience, knowledge, vigilance, prudence, awareness, or carefulness, to be able to fully control whether you commit an error or not, or overcome the human condition.”
Reblogged from “How to treat a man-slaughterer (or someone who made a fatal error)” from the “Mama I killed a man” blog, by Snagain.
Albert Wu (2000) Medical error: the second victim BMJ 2000;320:726
and Alleviating “Second Victim” Syndrome: How We Should Handle Patient Harm: By Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality. March 2012. Agency for Healthcare Research and Quality, Rockville, MD, on ‘The systemic nature of patient safety events’.
“What is striking about this description is its universality. Health care-associated injuries are events associated with the process or structure of care, rather than with a patient’s underlying or physiological, environmental, or disease-related conditions.”