![]() ![]() Staff error rate is only 1% - still an average of two per day per patient. The average ICU patient requires 178 actions per day. One of the most common diagnoses is ‘Other’. Despite intense specialization, in one year an average doctor might see 250 different primary conditions, work around 900 other active problems, prescribe 300 different medications, order 100 different lab tests, perform 40 different office procedures. Rough numbers - 13000 recognized diseases/syndromes/injuries, 6000 drugs, 4000 medical and surgical procedures. I am utterly blown away by the complexity described. These cases are rare not because we don’t have the technology, but because we don’t have the level of perfection it takes to get every single detail right. The entire process is astoundingly complicated and a single mistake, omission or slip of timing would have ruined it all. Went home after two weeks and within a few years made a complete recovery. How can we do better? The problem of extreme complexityĭescribes the process of reviving a girl who spent half an hour under icy water. The most experienced, highly-trained experts in the world still make simple errors of omission that cost lives. Often the difficulty is just in correctly applying them. Doctors and surgeons have many, many more tools and knowledge than before. ![]() High doses can stop the heart, so they fish out the bag and find that the concentration was accidentally 100x too high.Ĭomplexity of medicine has skyrocketed. Almost 15 minutes before the anesthesiologist is brought in and recalls that he was given a dose of potassium. A bayonet, not a knife.Ī cancer patient’s heart stops during surgery. Despite doing almost everything correctly, the ER team almost loses him because nobody remembers to ask what weapon he was stabbed with. Chapters IntroductionĪ stab patient in ER almost dies due to massive internal bleeding from his aorta, despite the stab wound being in his stomach. A simple checklist can often significantly reduce the error rate of even experienced professionals. Critical tasks are becoming more and more complex, requiring many more subtasks to be completed correctly. ![]()
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