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Never Event

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Re: Never Event

#21

Post by The_Colonel »

rob74 wrote: post #16
AmericanChopper wrote: post #14

Earlier quoted context omitted.

I think policies like vision zero are a complete governance anti-pattern. When you commit to a goal that is very literally impossible, it can be used as a justification for just about any action that would move the needle closer to the never-achievable target, no matter how insane that action might be. It is the complete opposite of sensible risk management, and serves only the politicians who find it difficult to pu…

If you asked somebody in the sixties whether it would be possible to have no airplane crashes, they would have laughed at you. And yet, the last crash of a commercial flight in the US is now 14 years ago. Of course, if everyone agrees that a goal isn't achievable (or it's not worth the effort to achieve it), then it will never be achieved...

Airliner safety boggles my mind. It's sort of banal, but mastering of such a complex system in a safe way is also one of the greatest achievements of human kind. So many things which can go wrong, yet it works.

Re: Never Event

#22

Post by praash »

I remember watching a surgeon-narrated YouTube video demonstrating eye removal, and didn't feel any stomach-turning horror from seeing the gore. I felt it when the narrator told to check something "to ensure the correct eye is being enucleated".

Re: Never Event

#23

Post by f2aaassa »

sidewndr46 wrote: post #4
benjijay wrote: post #3

A friend of mine has experienced Never Event #8 (Surgery performed on the wrong body part), went in for work on a tendon in her right ankle, woke up with a cast on the left leg. edit: scrolled further and saw that in the UK we have a different list, so I guess this would count as "Wrong site surgery"

can you elaborate? What did they actually do to the left leg?

The surgery they were going to do on the right one...

Re: Never Event

#24

Post by whatshisface »

cdkmoose wrote: post #13
whatshisface wrote: post #11

Earlier quoted context omitted.

It said "while being cared for in a healthcare facility." You can watch people and not leave dangerous objects around the room.

Depends n your definition of dangerous objects. For example, sheets?

Beds in psych wards usually have sheets. Suicide prevention is not like stopping the sane, rational Epstein from avoiding prosecution, it is more like checking in on people going through an awful experience every so often.

Re: Never Event

#25

Post by klyrs »

dhimes wrote: post #9
benjijay wrote: post #3

A friend of mine has experienced Never Event #8 (Surgery performed on the wrong body part), went in for work on a tendon in her right ankle, woke up with a cast on the left leg. edit: scrolled further and saw that in the UK we have a different list, so I guess this would count as "Wrong site surgery"

My friend is a surgeon. When he went in for knee surgery he wrote "Wrong Knee" on the good knee. He knows .

I've known people who have been asked by the surgical team to mark their own surgical site. But marking off the easy mistake in addition is even better.

Re: Never Event

#26

Post by sidewndr46 »

f2aaassa wrote: post #23
sidewndr46 wrote: post #4

Earlier quoted context omitted.

can you elaborate? What did they actually do to the left leg?

The surgery they were going to do on the right one...

but if the surgery is something like 'remove pin' how do they manage to perform that on the wrong leg?
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