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Rapid Responses to:
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Electronic letters published:
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif){kind=icon}
Focused Analysis of Medical Errors
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Kenneth K Kessler, MD University of Miami School of Medicine
Send rapid response to journal:
KMichaelKessler{at}cs.com Kenneth K Kessler
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TO THE EDITOR: Pronovost, Wu and Sexton (1) present an excellent in depth analysis of a medical error involving removal of a central line. Despite the value and increasing use of root cause analyses and system solutions to medical errors, it is often useful to determine the one person or circumstance that is “responsible” for the error, not to assess blame but rather to identify a focal point for future prevention. In this case the habit of dumping the “scut work” – routine removal of a catheter – on the least trained person appears to be pivotal. This seems lost in the analyses and “system factors” as summarized in the complexities of table 2. Clearly the person who assigned the first year fellow the task of removing the catheter without appropriate instruction is responsible. While system analyses may determine what fail-safes could have prevented inappropriate action and resultant harm, it is important to determine and specifically address the lynchpin of the system. References: 1. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004;140:1025-1033. Conflict of Interest:None declared |
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