Graham 1 Blakely Graham Professor Alicia Bolton English 101 November 21, 2013 Medical Mishaps Mistakes and

errors are made every day throughout the world. Some of them are catastrophic and may include the deaths of many people. Some include allowing terrorist attacks, plane crashes, fires, and mass shootings to occur. There could be many reasons these mistakes may have occurred: security wasnt good enough, the pilot was not paying attention to everything, someone left an oven on or a wire out, and maybe even somebody could have seen a person too young to be handling a gun and did not notify anyone. Many of these mistakes could have easily been fixed and therefore prevented the mass destruction and deaths caused. While these events are very large and spoken about often, there are some very small mishaps that cause only single deaths. These accidents may not be well-known and are often looked over by the mass population; however, these accidents may have a large impact on the people affected by these small mistakes. In Search of the Lost Cord, by Steven Casey, is about a four year old girl who has been battling birth defects and surgeries her whole life and is electrocuted because of a nurses error in hooking up her heart monitor. Nurse Karen Nessen plugged it into the IV causing the little girl to be electrocuted. Yes, this is a mistake that sounds very tragic, but do you ever hear about these events? Have you ever considered this happening to you or a loved one? Many people look these events over thinking, this could never happen to me; however, it very well could. Some people do not realize that even the smallest mistake, such as plugging a cord in the wrong connector, could kill them or their loved ones. While many people may argue and say that nurses and doctors are overworked, these tragic errors should not be occurring. These are all reasons that nurses and doctors should take better

Graham 2 protocol and be much more careful when handling the little actions of everyday events in their work field. While nurses and doctors make many mistakes, different organizations and medical statistics may say that nurses are over worked and exposed to danger. An article written by Bonnie Rogers, that was for the Encyclopedia of Nursing Research, includes statistics and claims that nurses are prone to make accidents because they are over worked, tired, and exposed to dangerous settings. It states that nurses *deal+ with the highly complex patient care, exacerbated by traditional patterns of work organization including long or unpredictable work hours, rotating shifts, and understaffing, is very stressful (Rogers, par. 2). This article also claims that many nurses are surrounded by patients who are not safe; Health care workers are at risk for verbal, psychological, and physical violence. Violent acts occur during interactions with patients, family, visitors, coworkers, and supervisors. Working with volatile people or people under heightened stress, long wait times for service, understaffing, patients or visitors under the influence of drugs or alcohol, access to weapons, inadequate security, and poor environmental design are among the risk factors for violence. (Rogers, par. 14) This statement gives adequate information to support the fact that nurses are exposed to dangerous and violent settings. Yes, these are all extreme working conditions; however, hospitals should hire more nurses so that they will not be as tired and overworked. When a person decides they want to be a nurse, they should know that their career is going to be stressful and dangerous. Nurses should be trained and prepared for these violent situations and dangerous settings. Mistakes that cause deadly situations are very preventable with the right training and preparation. Maybe nurse Nessen had been working a long time; however, this does not give her an excuse for plugging the heart monitor into the wrong connector. Because statistics and organizations prove nurses are over worked, stressed, and exposed to

Graham 3 danger, hospitals should realize this and make changes in scheduling and work to make the work place setting safer. There is no excuse for nurse Nessens mistake, and there are no excuses for other mistakes much like hers. In order to be more careful and take better protocol, nurses and doctors should take their time and make sure everything they are handling is in its proper place. This is a precaution that nurses and doctors should take at all times. Nurse Nessen bent over and grasped the end of the cord with her right hand and brought the two pieces together to connect them (Casey 178). Nurse Nesson should have taken the time to make sure the cords were in the right places before she ever planned on setting up the monitor. She also should have taken the time to really make sure she had the right connector, Healthcare professionals should put safety ahead of timeliness, had nurse Nesson put safety first and taken the time to check the cords she would not have made this mistake (Chilton). Many professionals believe that with the right amount of experience they do not have to take all the precautions. They just assume they are right and go on with their day to day actions. Nurse Nessen handled dozens of small machines every day and there was not a remote possibility in [her] mind that the cord was from anything but the heart monitor (Casey 179). This assumption should not have been made and in order to prevent mistakes like this again nurses should be trained to check everything thoroughly, no matter how much experience one may have. This nurse, like all other nurses and doctors, was handling machines that had enough voltage to kill a patient and she should have taken her time and made sure she was using the right cord. If doctors and nurses would take their time in their routines and make sure everything is in its proper place, then many of these mistakes, like nurse Nessens, would not be made. As well as taking better protocol and being more careful, doctors and nurses should pay attention to the medical error statistics and always be informed of why they are occurring. According to Dr. Donald Berwick, a professor for pediatrics and health care policy at Harvard Medical School who was featured in the film Killed by Care: Making Medicine Safe,

Graham 4 In the United States . . . we're losing somewhere between 44,000 and 98,000 people a year basically killed by their care instead of by their disease. That's more deaths than breast cancer, more deaths than AIDS, more deaths than motor vehicle accidents. So it's a very big number, and it's surprising to most people. It's urgent. It's urgent. This film was created to inform about an error that a hospital made that ended in the death of twelve infants. Dr. Donald Berwick is very correct. It is urgent. He states, Your chances of dying when you walk on a commercial airliner are 1 in 3,000,000. Your chances of dying when you walk into a hospital are 1 in 300. This is a shocking piece of information that Dr. Berwick brings up. The error presented in this film was completely caused by a hospital that, without taking their time and reviewing applications, hired an inexperienced surgeon who was hired without anyone ever checking his references. Yes, this mistake may seem extremely different from the mistake that nurse Nessen made; however, the little girl that died due to nurse Nessens error is listed under the same statistics as those twelve infants who passed away due to receiving heart surgery from an inexperienced surgeon. All of these mistakes can be avoided. This case really proves that hospitals do not take their time and review important information that should be used when hiring a new doctor or nurse. With the right doctors, surgeons, and nurses, accompanied by their abilities to take the right precautions, all thirteen of these inants would not have lost their lives. Another way doctors and nurses can take better protocol is to inspect cords, machines, and equipment regularly. These medical professionals should know exactly where each cord, plug, and switch is. Nurse Nessen should have known exactly where each plug was located before ever taking action to hook up the heart monitor. She should have known this with her experience with machines in her work environment. This is true in every medical situation that involves machines, cords, and anything that has an electric current; Electric shock may pose a serious hazard to both patients and personnel if safety precautions are not observed (Long 460). If nurse Nessen would have Inspected

Graham 5 equipment regularly, paying attention to cords and plugs she would not have made the mistake that was made (Long 459). She should have known where every plug and cord was placed. These cords also should have been more organized and put into place before any action was taken on the little girl. Electrical currents are a major hazard in the medical field and without the right precautions they could result in death or extreme damage to a human body. Another incident, where better protocol should have been used, occurred when a doctor was very careless and used medicine without checking it first. This incident ended in death too, just like the little girl under nurse Nessens care. In this incident a doctor accidentally injects the wrong drug into a patient. Dr. Yogasakaran, an anesthesiologist from New Zealand, was in control of giving a patient a dose of dopram; however, by not being careless and checking the drug he would have known he was injecting dopamine instead of dopram. It was ruled he was guilty of manslaughter, Yogasakaran failed to check the drug, a requirement acknowledged even by the expert called by the defense, had he checked the drug the patient would not have died and the doctor would not be in this situation (McCall Smith 14). This is a great example of how some doctors are careless and not concerned with taking their time and the right protocol in their work field. Dr. Yogasakaran should have taken his time and inspected the drug before handling the patient. This is much like nurse Nessens mistake. If she would have checked the plug more carefully she would have known it was the IV connector and not the heart monitor machine. These two mistakes, mistakes that were made within the blink of an eye, caused two deaths that should never have occurred. These two mistakes could have very easily been prevented had the doctor taken the time to check the medicine and the nurse taken the time to check the plug. Errors like the two that killed Dr. Yogasakarans patient and nurse Nessens patient are completely preventable and only occurred due to the carelessness of their actions. Although many precautions and protocols are taken in the medical field, there still arent enough. Do Doctors and nurses really take every single precaution there is on a day to day basis? Many

Graham 6 more precautions can be taken every day in the medical field. Doctors and nurses should pay attention to every medicine, procedure, and machine that has anything to do with a patient. Had many of the hospitals, doctors, and nurses taken better precautions half of the deaths due to medical errors would not occur. These are things the medical field needs to focus on. There is much room for improvement in the medical fields safety precautions and protocols. With less careless errors, more research when hiring, and more safety precautions involving medicines and machines, the high number of deaths due to medical errors would decrease.

Graham 7 Works Cited Chilton, Lynn. Medical Error Prevention for Healthcare Providers. Medscape. Web. 3 November 2013. Killed by Care: Making Medicine Safe. Medical Mistakes Kill Thousands of People Annually Films Media Group, 2004. Films On Demand. Web. 3 November 2013. Long, Bruce W. Safety and Inspection Control. Radiography Essentials for Limited Practice. 3rd edition Ed. Bruce W. Long, Eugiene D. Frank, Ruth Ann Ehrlich. Vol. 1. St. Louis, Missouri: Jeanne Olsen, 2010. 459-460. Print. McCall Smith, R.A. and Merry Alan. Errors, Medicine, and the Law. Cambridge: Cambridge University Press, 2001. eBook Collection (EBSCOhost). EBSCO. Web. 31 October 2013. Rogers, Bonnie. Nursing Occupational Injury and Stress. Encyclopedia of Nursing Research. Springer Publishing Company, 2011. n. pag. Credo Reference. Web. October 24 2013.