tag:blogger.com,1999:blog-23447705.post1211663745006274197..comments2024-03-29T09:06:26.510+11:00Comments on Australian Health Information Technology: Just Stop This Blame Rubbish! It Is Totally Clear Who Is To Blame!Dr David G More MB PhDhttp://www.blogger.com/profile/06902724829795199526noreply@blogger.comBlogger13125tag:blogger.com,1999:blog-23447705.post-53247797497678167652016-08-06T17:31:13.961+10:002016-08-06T17:31:13.961+10:00My understanding is that with 100% nitrogen the pa...My understanding is that with 100% nitrogen the patient rapidly desaturates their O2, and turns 'black'. I was speaking to a senior anaesthetic colleague who has been involved in writing the safety standards for the profession, and he said in this case the standard of practice is absolutely clear. One immediately disconnects the patient from the anaesthetic machine, and gives them room Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-23447705.post-63773142554625105902016-08-06T17:10:58.114+10:002016-08-06T17:10:58.114+10:00The fittings are different and you can't conne...The fittings are different and you can't connect them wrongly. The error has been in the plumbing from what I understand, with a nitrous line wrongly labeled as oxygen. Its terrible, but we need to await the investigation...Andrew McIntyrehttps://www.blogger.com/profile/17821423221138467536noreply@blogger.comtag:blogger.com,1999:blog-23447705.post-45301997325959627072016-08-06T09:16:34.140+10:002016-08-06T09:16:34.140+10:00I've lodged a couple of comments the last few ...I've lodged a couple of comments the last few das but they don't seem to be getting through.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-23447705.post-70311036568452254172016-08-05T11:22:59.421+10:002016-08-05T11:22:59.421+10:00Dear Dr Anesthetist - Surely there is a universal ...Dear Dr Anesthetist - Surely there is a universal standard with fittings specific for each gas to be piped. If Nitrous Oxide has one [specific male-female combination fitting, another gas had another male-female combination fitting, then the problem surely would not have arisen unless the wrong gas was in the wrong bottle. Does the manufacturer and the health system not have such basic solutions Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-23447705.post-87073622494636413062016-08-05T08:04:21.617+10:002016-08-05T08:04:21.617+10:00It's a simple problem to fix ....... different...It's a simple problem to fix ....... different gases should have slightly different fittings so they simply cannot be confused. I'd question why this has never been done. It's not rocket science but, ahhh.........perhaps it's an 'unnecessary' cost?Garry Boydnoreply@blogger.comtag:blogger.com,1999:blog-23447705.post-79605250659138338902016-08-04T23:11:04.414+10:002016-08-04T23:11:04.414+10:00Thank you for the level headed reply (not a compli...Thank you for the level headed reply (not a compliment)<br />How about - who does the ‘buck’ stop with?<br />1/ https://www.projecttimes.com/george-pitagorsky/failed-projects-who-is-responsible.html (maybe surgeons shouldn’t be ‘project leaders’ and accept they are part of a team)<br />2/ esoteric, but if you need, I can substitute nouns and adjectives.... http://guweb2.gonzaga.edu/faculty/alfinoBenedict 16thhttps://www.blogger.com/profile/18134731346603938206noreply@blogger.comtag:blogger.com,1999:blog-23447705.post-57019188881264350682016-08-03T17:38:18.185+10:002016-08-03T17:38:18.185+10:00Why not have slightly different fittings for diffe...Why not have slightly different fittings for different gases? A small investment to solve a problem that has produced devastating consequences. Garryhttps://www.blogger.com/profile/05531275795236790260noreply@blogger.comtag:blogger.com,1999:blog-23447705.post-7640096775612287262016-08-03T08:57:18.414+10:002016-08-03T08:57:18.414+10:00Its a horrific situation because the last thing yo...Its a horrific situation because the last thing you would want to do is take a patient doing badly off Oxygen, and the level of suspicion that the oxygen is not oxygen would be incredibly low.<br /><br />I think however its one of those events that is hard to prevent, its probably related to an unusual series of minor errors that all lined up in a row and allowed a catastrophe to occur. It Andrew McIntyrehttps://www.blogger.com/profile/17821423221138467536noreply@blogger.comtag:blogger.com,1999:blog-23447705.post-47028871098554125402016-08-03T07:35:19.449+10:002016-08-03T07:35:19.449+10:00David, I did a check on this to verify the followi...David, I did a check on this to verify the following. The )1 and Nitrous oxide outlets have DIFFERENT fittings so misconnection cannot occur.<br />If this is so then where did the system go wrong? It reminds me of the quote. "Most care accident are caused by the loose nut behind the wheel".Terry Hannanhttps://www.blogger.com/profile/04068727812313410493noreply@blogger.comtag:blogger.com,1999:blog-23447705.post-12658073691763518832016-08-03T06:56:35.841+10:002016-08-03T06:56:35.841+10:00Thanks Benedict...
When you pipe a building with ...Thanks Benedict...<br /><br />When you pipe a building with gas lines, you do it once, check it twice and then rely on the fact all the pipes from the wall to the patient are made so they CAN'T be connected wrongly. Equally the machines that dispense the gases are made in a similar safe way.<br /><br />It is utter negligence and incompetence that this could ever happen and it is the Dr David G More MB PhDhttps://www.blogger.com/profile/06902724829795199526noreply@blogger.comtag:blogger.com,1999:blog-23447705.post-1430878398954033322016-08-02T23:50:34.627+10:002016-08-02T23:50:34.627+10:00Who is going to pay for the compliance checking, a...Who is going to pay for the compliance checking, are you willing to take a 20% pay cut to help fund this???? No I don’t think so. Get off your high horse and pitch in with the rest of us... You arrogant ........<br /><br />If you think I am an upstart, go to NASA (would you like me to google that for you?) and loo at their systems for problems and near misses, then come back to me. <br /><br />Benedict 16thhttps://www.blogger.com/profile/18134731346603938206noreply@blogger.comtag:blogger.com,1999:blog-23447705.post-5144898627515098242016-08-02T20:36:06.103+10:002016-08-02T20:36:06.103+10:00Hardly ...once connected machines are used and con...Hardly ...once connected machines are used and connccted for years. The technicians need to check, be certain and we can all get on caring for our patients..<br /><br />David.<br /><br />Dr David G More MB PhDhttps://www.blogger.com/profile/06902724829795199526noreply@blogger.comtag:blogger.com,1999:blog-23447705.post-50084981423018603832016-08-02T20:29:48.003+10:002016-08-02T20:29:48.003+10:00I am no expert but should there not be some sort o...I am no expert but should there not be some sort of monitoring capability that machine checks this?Anonymousnoreply@blogger.com