تويت
A young mother RM died during a hospital admission for a planned caesarean delivery of her third child.
Her blood pressure plunged after delivery of a healthy baby girl. Staff did not pass on details of her condition and time was lost during treatment because her haemoglobin had not been measured before her operation. The instrument for measuring Hb levels could not be used because staff did not have an access password and the cartridges available were not suitable for use with the instrument.
A Quality System when functioning well identifies points of potential failure in a system allowing implementation of remedial action before there is a failure and harm to a patient. For the incident below:
• Make a list the errors that you think contributed to this failure.
• What remedial action would you recommend?
• How you would evaluate whether these solutions, if implemented, would prevent a repeat of the system failure.
I AM WAITING FOR ANY OPINION .......THANKS
Her blood pressure plunged after delivery of a healthy baby girl. Staff did not pass on details of her condition and time was lost during treatment because her haemoglobin had not been measured before her operation. The instrument for measuring Hb levels could not be used because staff did not have an access password and the cartridges available were not suitable for use with the instrument.
A Quality System when functioning well identifies points of potential failure in a system allowing implementation of remedial action before there is a failure and harm to a patient. For the incident below:
• Make a list the errors that you think contributed to this failure.
• What remedial action would you recommend?
• How you would evaluate whether these solutions, if implemented, would prevent a repeat of the system failure.
I AM WAITING FOR ANY OPINION .......THANKS
تعليق