Re: medical misadministration of I-131

[Michael Kay <makay@teleport.com>]

There are some areas where "Plain, old, simple human error" is not
acceptable--where your POSHE affects someone else. Mindfulness, concentration on
the task at hand, and following procedures WILL eliminate such errors. Assuming
that you have the right patient without following identification procedures is
Hubris--the prime ingredient for a tragedy.

Would you also say accidents are inevitable? Go tell that to the Dupont Chemical
Plant with a 26-year history of no lost time accidents, the foundry that passed
1,000,000 accident free work-hours. It depends on the culture of the specific
workplace--the responsibility of management.

The acceptance of such errors as unavoidable is part of a culture that will have
more happen. Apply the Motorola 6-Sigma Quality Standard to medical
administrations (the error is less than 1.0 minus the cumulative error
distribution for Z = 6 standard deviations). That would put the number of
misadministrations at 1 in 999999999+ or less than 1 per year worldwide.
This is achievable if you want it to happen. Management can make it happen.

Michael A. Kay, ScD, CHMM
HS&E Consultant
makay@teleport.com
"Grimm, Lawrence" wrote:

> Hi all:
>
> Sandy Perle and others have criticized a medical misadministration. I
>
> Does anyone want to guess what the major (90%) causative factor is for
> medical misadministrations?  Plain, old, simple human error.  Impossible to
> regulate, almost impossible to prevent.  Lest we chastise the medical
> community much further, let us all not forget the aphorism "He who casts the
> first stone..".  It would be lovely if I could say that I've never made a
> stupid mistake, but alas poor Yorick!
>
> Larry Grimm
> lgrimm@admin.ucla.edu
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