This is a report on an adverse incident which led to the demise of a patient, which involved administering an intravenal drug (via vein) intrathecally (via spine). The inquiry should be applauded for its indepth systemic investigation and far reaching recommendations. It shows how many people, assumptions, groups, technologies, labels, packaging and similar can interact to influence the likelihood of an adverse incident occurring.
The fact that this report has been made public should also be applauded - so as many people can learn from it as possible.
Subscribe to:
Post Comments (Atom)
No comments:
Post a Comment